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Who Gets A Choice?

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Is abortion care healthcare? In the United States, the answer to that question depends entirely on your ZIP code. In this episode, we’ll hear from two women, one in Texas and the other in New York, both working against the clock to access an abortion.  How do abortion restrictions impact pregnant people’s healthcare? What does it mean to be treated with dignity and compassion? And what is at stake for pregnant people and medical providers in this country?

Uncared For is presented by the Commonwealth Fund, a nonprofit foundation making grants to promote an equitable, high-performing health care system. Learn more at CommonwealthFund.org.

SuChin Pak is our host. Muna Danish is our supervising producer. Giulia Hjort is our producer and Rachel Lightner is our producer and audio engineer. Isaura Aceves is our associate producer. Mix help from Kristin Mueller. Music is by Andrea Kristinsdottir. Jackie Danziger is our VP of Narrative Content. Our story consultant is Kaya Henderson. Fact-checking by Naomi Barr. Executive producers are Jessica Cordova Kramer and Stephanie Wittels Wachs.

Follow SuChin on Twitter and Instagram at @suchinpak. Stay up to date with us on Twitter, Facebook and Instagram at @LemonadaMedia.

Learn more about maternal mortality review committees in your state here: https://www.guttmacher.org/state-policy/explore/maternal-mortality-review-committees.

Learn more about Kathy Kleinfeld’s clinic, the Houston Women’s Reproductive Services, here: https://houstonwomensreproductiveservices.com/.

Looking for abortion care? Search state-by-state information using the links below:

Want more information on safe, at-home abortion pills? Visit: https://www.plancpills.org/.

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To follow along with a transcript, go to www.lemonadamedia.com/show/ shortly after the air date.

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Veronica Gillispie-Bell, SuChin Pak, Jackie, Speaker 3, Kathy Kleinfeld, Speaker 7, Speaker 4, Speaker 5, Speaker 8, Selena

SuChin Pak  00:00

Please note that this episode contains descriptions about miscarriage and abortion. Please take care while listening.

Selena  00:09

The first thing I did was I called my sister and I was sobbing and I was telling her I was like; I think I’m pregnant. And did you just see the news? What I was told from my friend was, don’t text about it, don’t call about it. Don’t write on social media.

SuChin Pak  00:50

This is Selena from Houston, Texas. We’re using her first name only for privacy reasons. This past summer, Selena did something she’d never imagined having to do. She terminated her pregnancy with abortion pills. Pills given to her by a stranger.

Selena  01:06

There was just pills, cut out a foil and a little plastic baggie with a handwritten note folded up in a brown paper bag. It take this many at this time. And if you feel like it’s incomplete, take the last four, and then you should be good. Like, that’s really freakin scary.

SuChin Pak  01:28

On June 24 2022, after nearly 50 years, the constitutional protection for abortion in the US was reversed. Overnight abortion was effectively illegal in Texas. Almost half of the country lost access to abortion care once trigger bands went into effect. Today, 14 states have total or near total abortion bans, a number that remains in flux. But this is about so much more than abortion. In our country, health care and health equity have always been deeply intertwined with politics. Nothing illustrates this more clearly than abortion care. The fact is, we cannot separate maternal health care from abortion care, because they’re one in the same. The care for a miscarriage or ectopic pregnancy or a number of other life threatening pregnancy complications is often the same medical procedure as an abortion. And the clinics where you get an abortion often provide all sorts of other health care services. So when we lose these clinics and providers, we also lose access to services like STI testing and treatment, contraception, management of early pregnancy issues and screening for chronic health conditions. It’s a domino effect that goes well beyond abortion. And the people who will be most hard hit by these new restrictions are people of color, low income communities and those living in rural areas. And nowhere is that clearer than in Texas, where there is currently a full ban on all abortions unless the pregnant person’s life is in danger. It’s a way to preview if you will, what’s at stake for both pregnant people and providers in a post-Roe world.

Speaker 3  03:23

This recent decision by the Supreme Court is going to have a significant impact on our ability to achieve health equity.

Speaker 4  03:31

It’s disrupting our systems of care. And whenever the systems of care are disruptive, black and brown people are going to suffer the most

Speaker 5  03:40

To force people into carrying a pregnancy to term when their risk of death and dying is higher is an abomination.

SuChin Pak  03:50

Today we’re going to dive into the weight of these rulings on the maternal health of so many in the US, including how these restrictions only lead to more inequity in an already broken system. This is UNCARED FOR, I’m your host SuChin Pak.

Selena  04:16

Once it popped up, like my heart just dropped.

SuChin Pak  04:20

That’s Selena again, the day after Roe was overturned, she took a pregnancy test. And the faint positive line she saw left her in complete shock.

Selena  04:30

This couldn’t have happened because we were preventing we were doing all things that we thought we needed to do. And we were not ready for this. I think I sat in the bathroom by myself for like, I don’t know 10-15 minutes just looking at it. I remember I texted my friend a picture of it like are you seeing this is this real?

SuChin Pak  04:55

Selena and her husband Austin had recently celebrated their daughter Brinley. He’s first birthday, and then we’re just settling into their new normal. Before then, Selena had suffered two miscarriages within five months of each other.

Selena  05:09

I had just gone through two years of hormones of being pregnant, not pregnant, pregnant, not pregnant, pregnant, having a baby breastfeeding, all of that, like my body physically is not okay. I’m not mentally okay yet.

SuChin Pak  05:25

Both of Selena’s miscarriages resulted in D&C or dilation and curettage, a surgical procedure like clears tissue from the uterus.

Selena  05:34

I wasn’t ready to have another child because of everything we had just gone through. I felt like I was taking time away from my daughter that we’ve worked so hard to get into this world. I was scared financially. I was scared that I didn’t have a decision.

SuChin Pak  05:52

Selena knew that living in Texas, her options for a legal abortion were growing more limited by the day. Over a week before the overturning of Roe, the local Houston Planned Parenthood had anticipated the worst possible outcome. So they had stopped providing abortions altogether. At the time, only a few abortion clinics were operating in Houston and only around 20 clinics were serving the entire state of Texas, the second largest state in the country.

Kathy Kleinfeld  06:22

The finality of this and the severity of overturning, and almost 50 year old precedent was just more than any of us could have ever expected.

SuChin Pak  06:37

That’s Kathy Kleinfeld co-founder of the medication abortion clinic, Houston women’s reproductive services. Cathy’s clinic helped with the overflow of abortion patients from the Houston Planned Parenthood while they still could. Because having been in abortion care in Texas for 30 years, Kathy had a sense of what was in store.

Kathy Kleinfeld  06:58

As much as we knew this was probably going to happen when it actually happens, you can never really prepare yourself for how it’s going to feel.

SuChin Pak  07:08

The news broke on a Friday around nine in the morning, and patients were at Kathy’s clinic waiting for care.

Kathy Kleinfeld  07:15

And our lawyers called us immediately and said you cannot provide any more abortions today. You’ve got to stop right now. There was disbelief, anger. I mean, we had patients in the exam rooms, and we had to go in and tell them that we couldn’t take care of them. One woman had driven over from Alabama. And she had to leave here still pregnant. You know, there were so many tears. It was so emotional. I remember one person in particular. And all I could think of was like a caged animal. She was literally pacing. I mean, I could hear her. And she even said, I don’t know what to do. I don’t know what to do. I don’t know what to do. I mean, I felt like I was talking someone off of a ledge. And we just had to go into, you know, survival mode and figure out what can we tell them? Where can we tell them to go? What’s available, and it all had to be done in real time.

SuChin Pak  08:28

Survival Mode was also top of mind for Selena. To double check what she was seeing on her pregnancy test. Selena called the clinic just outside of Houston and got an appointment for two days later. But as you might imagine, things didn’t exactly go as planned.

Selena  08:44

So I went to the doctor’s appointment on June 27th. And they did trans vaginal ultrasound, and they had seen nothing, but they did also do a pregnancy tests there which was positive, as positive can be she said.

SuChin Pak  08:59

So Selena decided to ask about abortion pills, which that clinic was still providing.

Selena  09:05

But what I was told was that they couldn’t help me and give me that pill because they physically needed to see something on the ultrasound.

SuChin Pak  09:13

Selena was just too early in her pregnancy for to show on the ultrasound. At this point, it had been three days after the overturning of Roe but the impacts of it were yet to be seen on a wide scale. And this was confusing for a lot of people seeking abortion care on a timeline like Selena.

Selena  09:34

Texas was still in that gray zone of okay, well, they’re giving us 30 days but they might not be giving us 30 days.

SuChin Pak  09:43

This gray zone was supposed to translate into a sort of grace period before the Texas trigger law would go into effect. But in reality, there was just a lot of confusion at the clinics.

Selena  09:55

There was like a lion out the door and it just felt like chaos. like people were scrambling like, Okay, I need to figure this out because I have a timeline now.

Kathy Kleinfeld  10:06

Everyone thought that we had the 30 days. But we did not. It was immediate.

SuChin Pak  10:14

That’s Kathy Kleinfeld again.

Kathy Kleinfeld  10:17

There’s the old law that was on the books from before Roe vs. Wade, that has never been overturned. Our Governor and Attorney General said that immediately, the pre roe ban would go into effect. So there was a lot of confusion about that.

SuChin Pak  10:35

What Kathy’s talking about are these 165 year old pre Roe statutes in Texas law that criminalized abortion with prison time of up to five years. When roe became the law of the land, these outdated statutes were ruled unconstitutional and blocked. But they were never actually repealed. They just kind of faded into obscurity. So nearly 50 years later, when Roe was overturned those statutes well, they were still technically on the books. So all abortion clinics in the state stopped providing abortion care almost immediately for fear of criminal liability. Luckily, Kathy’s clinic was one of three clinics that were able to get a temporary restraining order to block that law from going into effect right away.

Kathy Kleinfeld  11:29

So we were able to see patients on Tuesday, Wednesday, Thursday, and Friday of that following week, and we had warned all of them, you know, we have a temporary restraining order. But if the Texas Supreme Court overturns that, then you’ll get a call from us and we won’t be able to see you.

SuChin Pak  11:51

This is because Texas law required a 24 hour waiting period for people seeking an abortion. So some of Kathy’s patients who came in during the week for an ultrasound, were planning to return on Saturday to actually get the abortion pills. And things were business as usual, until Friday, July 1st, the day before the holiday weekend.

Kathy Kleinfeld  12:14

And at nine o’clock at night, the lawyers called me and said the Supreme Court overturned the temporary restraining order. You can’t see any patients. You’re done. That’s it.

SuChin Pak  12:32

This meant that all those patients who had been counting on their scheduled abortion on Saturday had to be contacted. by canceling these appointments at the very last minute, Kathy felt like she was letting a whole lot of people down. What would these people do now? Where would they go? Would they be able to find a safe alternative?

Kathy Kleinfeld  12:54

You know, they were like waiting for the worst possible time. Texas is a cruel state for pregnant people. That’s the bottom line.

SuChin Pak  13:11

And the reality of abortion care in Texas was about to become even more bleak. On top of the pre roe ban. A separate trigger law that passed in Texas only a year earlier, would kick in on August 25. And the penalty for an abortion would skyrocket up to life in prison. The clock was ticking for providers and patients. Which brings us back to Selena. After that first visit to the clinic. Selena knew she had very little time to get the care she needed. The preexisting ban meant that she could no longer get a legal abortion.

Selena  13:48

This was no longer about me and my body. This was someone else making decision when they know nothing about my medical history about my mental history about anything like that. So

SuChin Pak  13:59

Selena started looking for alternative solutions, her plan, get her hands on some abortion pills.

Selena  14:07

I just wanted to put the ball in motion. Just to know that like, if this is what I want, like I can have it at my fingertips. I immediately had called my friend and was like, I need you to call your friend and get me the pill.

SuChin Pak  14:25

Luckily, Selena’s friend knew someone who could get her the […] abortion pill. Within an hour, her friend had made the call. And the next day Selena had the pills in her hands.

Selena  14:36

I was handed a brown paper bag with some random pills in it was some handwritten note. And it was basically like, okay, here you go. Here’s your instructions. So, to me, I felt relief in that moment, but at the same time, I was scared shitless because here I am, about to take a pill from some person, I don’t know. But to me, that was my only option at the time because the doctors here are telling me they can’t help me. So I’m just going to do whatever I need to do.

SuChin Pak  15:14

After getting the pills, Selena went back to the clinic for a second ultrasound to confirm the pregnancy. And to try just one last time to get the Plansee abortion pills from a more credible provider.

Selena  15:27

She basically said, Yep, there it is. There’s a baby, but we can’t help you. Do you need resources? Can I give you a number to call? I could see in her face that she was sympathetic, and she wanted to help but she couldn’t help me. Her hands were tied.

SuChin Pak  15:45

That second clinic visit helped Selena come to a firm decision about what she thought was best for herself and her family. A couple days later, she started spotting.

Selena  15:56

And to me I was thinking like, okay, well, I’m having a miscarriage. If I’m spotting, I’m having a miscarriage. So I’m just going to take these pills to assure that it expels entirely. So that evening, I had taken the first set of the pills, and within like four hours, it all started to come out.

SuChin Pak  16:19

And that’s when Selena’s fear really set in.

Selena  16:24

I was in so much pain, you know, my parents were in town, I had to just tell them that I was having a horrible period. And I had a headache, but I was fine.

SuChin Pak  16:37

But Selena was anything but fine.

Selena  16:40

What’s gonna happen to me, like, am I going to die? Now? That’s my thought, like, I’m running through this whole process through my head, like, you know, am I going to bleed to death? You know, is this not going to fully expel itself? And now I’m gonna have to go the hospital anyways. And I don’t want to tell them what I took. What if they find out? Am I going to go to jail? Is my daughter not going to have a mom now, because I tried to do something for our family that put me at risk. And to not be able to call a doctor to ask like, is this normal? Just, you’re just hoping for the best here.

SuChin Pak  17:20

Selena was okay, at least physically. But she’s still working through the emotional turmoil to this day.

Selena  17:27

I sat in a lot of guilt, and I felt ashamed about the decision that I felt that I had to make. And that that didn’t go away for quite some time. I’ve really worked on myself to realize like, I did this for my family. I did this for a positive reason. And I don’t need to feel ashamed.

SuChin Pak  17:56

There are two aspects to Selena story that feel like some kind of dystopian horror movie to me. One, that in Texas and many other states in the country, your providers can be criminally charged for your medical care, and two, when you’re at your most vulnerable, making a difficult decision for the health of your family. The government has the final say. At the end of the day, this was a personal decision that became impossible for Selena to make. She jumped through so many hoops to get the safest abortion possible in the state of Texas. And her best possible solution came in a brown paper bag from a stranger. The reality is abortion bans aren’t going to reduce the number of abortions, they’re just going to make them less safe and cause lasting trauma. After the break, we leave Texas and see how abortion care is impacting pregnant people in other parts of the country. With the fall of Roe abortion access now entirely depends on what state you live in. If you’re in Texas, like Selena and Kathy, you have virtually zero access to abortion, but in other states like New York, abortion can be fully integrated into your maternal health care. And that’s where Jackie lives. Again, we’re only using her first name for privacy reasons. When Jackie found out she was pregnant last year, she was beside herself with excitement.

Jackie  19:36

I was completely speechless, and I couldn’t believe it and my husband was with me and he was so excited that he literally started to dance.

SuChin Pak  19:45

Jackie and her husband were ready to start a family and they found out they were pregnant earlier than they had expected. So they just felt really lucky.

Jackie  19:54

Around 12 weeks we found out that we were having a girl that was also just the most exciting thing possible, cuz I’d always wanted a daughter and so that just felt like it was meant to be. And from that point on, we started thinking about names. We chose one, she was Fiona.

SuChin Pak  20:12

After the 12 week scan, the two of them felt reassured, they started calling family and friends updating them about their tiny family member to be. But there was still one pregnancy milestone that was looming over Jackie’s head.

Jackie  20:26

The 20 week scan is where you really get to see the baby’s organs. It’s called the fetal anatomy scan. And that’s like the big one. So, leading up to it, I was extremely anxious. I just knew that a lot was riding on that scan.

SuChin Pak  20:42

When they arrived at the hospital, the ultrasound tech was super friendly and upbeat.

Jackie  20:48

Your baby is so active and you know so uncooperative, like they’re very, very cutesy kind of jokey about it.

SuChin Pak  20:54

But soon enough, Jackie and her husband noticed that things were taking a while.

Jackie  21:00

It was at the point that they were looking at her spine and her hands that they couldn’t get a clearer image. So they kept looking. And the ultrasound tech was a little quiet, little bit frustrated. 40 minutes turned into 50 minutes an hour passed.

SuChin Pak  21:17

And after that excruciatingly long hour, they asked Jackie to come back another day, they would need to do the ultrasound again, to get a clearer picture.

Jackie  21:27

We asked Is there a problem? They said, No, no, it’s just a matter of you know, baby didn’t cooperate, we couldn’t get the right position. Come back next week. In my mind, we’ve passed I’ve been so nervous about 20 weeks, it was like great, there was no problem. We just felt like we were out of the woods.

SuChin Pak  21:45

So the next week, Jackie came back for ultrasound. Number two.

Jackie  21:50

Basically, I’m on the bed. And you know, my stomach’s covered in that slimy goo that they put on you for the exams. And the ultrasound tech kept pushing really hard on my stomach trying to get these angles. And the more she was looking, the more quiet she got.

SuChin Pak  22:09

The tech kept trying to get a few more angles prodding and pushing for a good look. Then she told Jackie, okay, I think these ankles are good enough. But let me grab the doctor just to make sure. Reasonable enough, Jackie thought.

Jackie  22:24

It wasn’t until the doctor came into the room and looked at us and said I have some hard news that we even realized that there was a problem. The doctor pulled out a piece of paper and she said, we’re looking at three different diagnoses.

SuChin Pak  22:44

Jackie was blindsided. A second ago, things seem to be moving along fine. Now her doctor was throwing out words like diagnoses.

Jackie  22:53

They saw something on her spine. There was some sort of a growth, they didn’t know what it was for sure. And that it was very small.

SuChin Pak  23:02

Jackie was told to get a fetal MRI to see the baby more clearly. But she could barely take in what she was hearing. At that moment, time felt like it was standing still.

Jackie  23:14

It was extreme panic, but also fear. And in my list of all the things that could potentially go wrong, I just didn’t even think about her spine. And I just remember when she explained the possibilities of what was going on. I just thought I’ve already missed something as a parent. It felt like I was falling into this abyss of no information, and nothing I could do about it.

SuChin Pak  23:54

Jackie is a self-described compulsive planner. But at this moment, she was for once in her life at a loss of what to do.

Jackie  24:03

And after she had read us all of the possible diagnoses she said you should know that now is the time to consider terminating the pregnancy. If that is something you want to consider, because you have limited time.

SuChin Pak  24:21

Jackie and her husband only had 10 days to make their choice because New York’s cut off for most abortions is 24 weeks. At this point, Jackie was at 22 and a half weeks the clock was ticking. So right away she scheduled the fetal MRI.

Jackie  24:39

The fetal MRI machine is really loud. So the second I got quiet, the machine just started blaring it was almost like an alarm going off in my ears. And because it was still so early in the pregnancy for this kind of a scan. It took them almost two hours to get a clear image.

SuChin Pak  25:00

Two hours flat on her back 22 weeks pregnant. If that’s not bad enough, the MRI happened to be scheduled the day of her 34th birthday.

Jackie  25:11

So I went home, and my husband and my best friend tried to have like a birthday celebration, which was just ridiculous. We literally had an ice cream cake delivered. And it was like 10 minutes after this cake had arrived, we got a phone call, and it was the doctor. And she said that things look much worse than they initially thought.

SuChin Pak  25:33

It turned out that Jackie’s baby had a rare fetal anomaly. They were told to get in touch with a pediatric neurosurgeon for more information.

Jackie  25:43

It was the first time that I thought to myself, I don’t know if I want this, I don’t know that I want this life for my baby and for us. And that felt very complicated and terrible.

SuChin Pak  25:57

A few days later, Jackie and her husband called the neurosurgeon.

Jackie  26:01

She said that what we would be looking at was a very hard road. And some of the things that we were looking at was a child that would never learn to walk, they would have no control over their bladder, would not really be able to live with any autonomy.

SuChin Pak  26:22

This meant a lifetime of surgeries. And that was the best case scenario, there was a very real possibility that the child wouldn’t survive into adulthood. It was a lot to take in. But on top of the crushing news, Jackie was also facing a crushing timeline.

Jackie  26:43

There was no breathing room whatsoever to try to find extra second opinions or to really, you know, think out the options. I mean, we really just had to go off of our instincts. I felt like for that week, I’m suddenly driving a car and I have no idea how this thing works. You know, none of the doctors can tell you exactly what to do. All they can tell you is that things look bad, and there’s no time to try to get more information.

SuChin Pak  27:14

Later that night, Jackie made her final decision.

Jackie  27:19

Even though it was terrible. I knew that it was the right thing to do. I feel like I’ve been staunchly pro-choice my whole life. And I still am. And part of that was always feeling very unapologetic about it. And this was the first time ever that I just had the guilt associated with the choice. Not because I feel like it is wrong, but it felt very sad and horrible. To let go of the dream that was at baby.

SuChin Pak  27:55

More of Jackie’s story after the break.

SuChin Pak  28:09

Because of how far along Jackie was her abortion procedure took two days, easily the worst two days of her life. But once it was over, the clouds finally started to clear.

Jackie  28:22

On the way home for the first time, I actually felt relief that I didn’t have to think about making this choice anymore. The choice had been made. And once I was on the other side of it, I knew that it was the right choice for me.

SuChin Pak  28:39

Jackie was especially grateful for one thing that she lives in New York, a state where an abortion at 24 weeks is still legal.

Jackie  28:49

I cannot I cannot imagine if I had had to survive this anywhere other than where I lived. I think about all of the difficult decisions I had to make and all of the painful conversations and just things I had to process in that time. If I also had to think of travel plans and finding a new doctor finding a new facility getting on a plane. I think that would have destroyed me. I don’t think I could have survived that.

SuChin Pak  29:21

She was grateful for her care team who was there for her every step of the way.

Jackie  29:26

Throughout this whole process. We never talked about abortions. That word never came up. It was always a series of health decisions made about this pregnancy. I don’t think we should be ashamed or hesitant to use that word. But I wasn’t thinking about some large political debate when this was going on.

SuChin Pak  29:47

Jackie didn’t feel like she was having a capital A abortion because it wasn’t painted that way by her providers. Instead, it felt like one more decision that needed to be made for the health of her family.

Jackie  29:59

I imagined like abortion is what you have at a clinic. It’s like separate from like your actual like day to day health care experience, you know, but it wasn’t, it was all attached to the same doctors I had been working with. And I think because of that, it didn’t feel like it was the sideshow to health. It was just a part of my health care decisions. And that made it feel less scary, it made it feel astigmatized.

SuChin Pak  30:26

Jackie had what we call the best case scenario of the worst case scenario. She had supportive care throughout, from a team that cared for her before, during, and after her decision.

Jackie  30:38

The same person who helped me through ending a pregnancy helped me when three months after ending this pregnancy, we knew that we were ready to get pregnant again.

SuChin Pak  30:52

And that’s where the silver lining comes in. A little over a year later, Jackie, and her husband had a healthy baby girl.

Jackie  31:00

You know, I pushed for 15 minutes and my baby came into the world. And it just was this moment where time felt like it was on my side and everything was suddenly best case scenario in a wonderful way. And it was like we’ve waited so long for her to get here that she didn’t make us wait any longer. I realized that being able to have this choice has put me in the position that I’m in right now. Where I am a mom, I have a healthy, happy baby. And I’m experiencing so much joy. And I’m allowed to have this joy because I had the choice. To do this on my own terms, the way that I hoped and dreamed for.

SuChin Pak  31:44

Hearing Jackie’s story, I can’t help but think like so many other problems in our country. We are divided again between the haves and the have nots. Those lucky enough to live in states that have medically sound approaches to abortion care, or those that have the financial means to travel for an abortion versus the people who can’t, or people who live in the most restrictive states. In some ways. Jackie’s experience of receiving compassionate and integrated care is the highest standard of what maternal health care can be in our country. She didn’t have to buy abortion pills on the black market, or traveled hundreds of miles to a clinic where wait times can last days or weeks. Everything about Jackie’s experience was focused on medical decisions made alongside her team of providers. But since the fall of Roe, these medical decisions are under attack for many providers, especially in states with abortion bans. Now providers all over the country are grappling with what this will mean for them and their patients.

Veronica Gillispie-Bell  32:52

I knew that it was a possibility. I knew it was a strong possibility. And then when it happened, it was such a letdown. I could see the almost the wheels falling off the bus or the yarn unraveling.

SuChin Pak  33:18

That’s Dr. Veronica Gillespie-Bell, the OBGYN We met in episode one.

Veronica Gillispie-Bell  33:23

It wasn’t just the fact that now women could not choose their reproductive path. But I saw all of the unintended consequences that were going to come out of this.

SuChin Pak  33:37

Doctor good Gillespie Belle’s practice is based in Louisiana where abortions are now banned, except in cases of medical emergency. But determining what a medical emergency is, is not so black and white.

Veronica Gillispie-Bell  33:51

We’re talking about physicians making clinical decisions, but this is being judged in a legal way. So legally, who is going to decide that this is to protect the mother’s life, nobody wants to have a threat of having to go to court have them being criminally charged. And so I think just that in itself is enough that makes physicians just not move forward with doing abortions even in situations where they would be approved.

SuChin Pak  34:20

So providers are caught in a dangerous catch 22 either a risk a patient’s life by denying the abortion or be risk serving prison time if they do perform the abortion and it’s deemed unnecessary. So all in all, not great options.

Veronica Gillispie-Bell  34:38

In Louisiana, if you perform an abortion as a provider, and it is deemed not to be, you know within the exceptions, then you can go to jail for 10 years and be fined $10,000 this is being criminally charged. So I mean again, the stakes are very, very high.

SuChin Pak  35:01

Veronica’s fears are represented in the research. One article on the adverse effects of SB8 published in the New England Journal of Medicine shows how this law had a chilling effect on practitioners, meaning that just out of the fear of being sued, providers were reluctant to offer abortion care. And that’s what was dictating their decisions, fear. This fear trickles all the way down to the basic health information patients receive. For example, some doctors said they wouldn’t even mentioned abortion as an available option, because that might be seen as aiding and abetting. The legal stakes aren’t just high for doctors, pregnant people are at a major risk of being criminalized too. But legal implications aside, one thing is certain, abortion bans impact maternal care, and ultimately health outcomes. One study from 2021 found that a total ban on abortion could increase pregnancy related deaths up to 21% and up to 33% for Black birthing people. Another study found that even delays in abortion care a to Dallas hospitals lead to serious health consequences like hemorrhaging, infection, and even a hysterectomy.

Speaker 4  36:25

Anytime a system is broken or backed up, then they’re going to be delays in care, even if it’s indirect.

SuChin Pak  36:33

Increased wait times will likely be a reality for most abortion clinics across the country, as more and more people travel out of state for abortion care, which means more money and higher risks. And like Selena and Jackie’s stories showed us many people are up against the clock when seeking abortions, which makes this new reality all the more alarming. Dr. Gillespie Bell is particularly worried about the future of states like Louisiana, which only had three abortion clinics even before Roe was overturned.

Veronica Gillispie-Bell  37:08

So we in fact, have really a dearth of obstetric care providers. So if we’re decreasing that even more than you know, that’s decreased in Access. And I think it’s going to be very difficult to attract providers to come to practice in the state where they have to be concerned about going to jail for practicing medicine. So that’s a concern. And then additionally, if we’re having to go miles and miles and miles to get to a birthing facility with trained providers, then those are delays in care. And that’s increased morbidity and mortality.

SuChin Pak  37:44

It’s not just abortion care. For some an annual clinic visit is the one doctor’s appointment, you actually go to all year, you might go to get birth control. But once there, you get checked for high blood pressure or tested for a chronic illness. And the loss of these providers means even less access to basic care. And then there’s the ripple effects that we’re only just starting to see, like the impact these restrictions will have on medical training and education, there is a real possibility that a whole generation of providers might not even know how to provide early pregnancy management and abortion care.

Veronica Gillispie-Bell  38:24

And whenever the systems of care are disruptive, black and brown people are going to suffer the most.

SuChin Pak  38:30

In addition to people of color, these barriers will affect anyone who is low income. And the US already has pretty glaring gaps in this regard. Compared to other developed countries, the US consistently has the largest disparities between income groups in terms of accessing medical care, abortion has become in some ways, just another aspect of medical care. That depends on where you live and your income.

Veronica Gillispie-Bell  38:56

Traveling out of state. Okay, so who’s able to do that? Well, people with means. If you have the means, you know, it’s Oh, okay, well, it will be a little more inconvenient, but I have a job that allows me to take time off. I have the money to get on a plane and fly. What about all those people without those means?

SuChin Pak  39:21

Kathy’s absolutely right. These restrictions will disproportionately impact people of color and low income folks, not to mention those who can’t travel due to their immigration status, which is not an insignificant number in a border state like Texas. So what can we do? Well, aside from establishing more abortion protections, there are some options that are still on the table. Let’s go back to the beginning with Selena’s story. She went the abortion pill route, which is an option that’s becoming more reliable and safer. Thanks to the internet.

Kathy Kleinfeld  40:00

We are seeing that that has been a resource for a lot of people, and a lifeline for a lot of people because some of those, some of those organizations are providing the pill, a no cost if people can’t afford it.

SuChin Pak  40:14

While abortion medication is still an option for now, it’s hard to say what the future will hold. But Kathie remains optimistic. After all, some states are mobilizing to ensure abortion rights. This past August in the largely conservative state of Kansas, constituents successfully voted to preserve abortion protections rather than restrict them. And just last week, ballot measures to establish the right to abortion passed in three more states across the US.

Kathy Kleinfeld  40:46

So, you know, we look for those silver linings and the hope where we can get it. And we know that this has been a wakeup call for a lot of people. I have heard from a lot of people who said I’ve never been a single issue voter, because I never really thought this was ever going to happen. And they will say And shame on me that I didn’t really fully understand that this could happen.

SuChin Pak  41:17

Well, it has happened. And here we are. While there is hope in medication abortions, I gotta point out that the state of reproductive care in the US is not looking great, when the most reliable way to get an abortion is through the internet or a brown paper bag handed to you by your stranger. It feels like such a fragmented system living in a country where care can vary so widely depending on your zip code. And a system was so many inequities already restricting abortion care will only widen those gaps. And it’s not just abortion. So many types of care depend on which state you live in, your income and what’s covered by your insurer. It can be infuriating to think about how much politics influences our ability to take care of ourselves.

Kathy Kleinfeld  42:12

People are starting to recognize this really isn’t just an issue about abortion. It’s about control, bodily autonomy, it affects everybody. You know, the decision is so fundamentally private and basic to our rights. And it only rests with the individual, not with the government.

SuChin Pak  42:35

As for Kathy’s clinic, Houston women’s reproductive services, well, they’re still operating. But for now, they can only offer ultrasounds and referrals out of state.

Kathy Kleinfeld  42:45

We’re not ready to give up. We’re gonna keep the doors open as long as we can. We’re ready to challenge anything, any challenges they give us. We’re gonna be here. We’re not going anywhere.

SuChin Pak  43:04

As we heard throughout this episode, the outlook for maternal care and reproductive rights in the US is not looking so good. But luckily, that’s not the case everywhere. In fact, other countries are already many steps ahead of us. Next episode will travel to Germany where childcare is subsidized, and everyone has a legal right to a midwife.

Speaker 7  43:29

In the end, you have the feeling that you didn’t have a midwife but you actually had a friend who coached you through this whole situation.

SuChin Pak  43:36

We’ll also meet an American who moved to Germany after having her first child.

Speaker 8  43:42

Daycare. It was literally like bankrupting us in Portland. And I think we were both kind of like, would we rather stay here? Or would we rather be in a place where we have free childcare?

CREDITS  43:54

UNCARED FOR is a production of Lemonada Media. I’m your host SuChin Pak. Muna Danish is our supervising producer. Giulia Hjort is our producer. And Rachel Lightner is our producer and audio engineer. Isaura Aceves is our associate producer. Mix help from Kristin Mueller. Music is by Andí Kristinsdóttir, Jackie Danziger is our VP of narrative content. A story consultant is Kaya Henderson. Fact checking by Naomi Barr. Executive Producers are Jessica Cordova Kramer and Stephanie Wittels Wachs. This season of Uncared For is created in partnership with the Commonwealth Fund. There’s more UNCARED FOR with Lemonada Premium subscribers get exclusive access to bonus content, like interviews with health experts, midwives and doulas. Subscribe now in Apple podcasts, follow UNCARED FOR wherever you get your podcasts or listen ad free on Amazon music with your Prime membership.

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