The patient on 9 March was a tricky case.
She was pregnant and seeking an abortion, but had previously had a cesarean section, which could create complications if the placenta embedded in her surgical scar. Houston Women’s Reproductive Services couldn’t perform the procedure because Texas had banned abortions, but the clinic could do an ultrasound and communicate with the provider in New Mexico, where the patient was heading for her appointment. Then, once the patient was back in Texas, the Houston clinic would provide any follow-up care and support she needed.
Before the supreme court ruled in Dobbs v Jackson Women’s Health Organization, Houston Women’s Reproductive Services (HWRS) provided medication abortion to about 50 patients a day. When it became clear that the overturning of Roe v Wade was imminent, the clinic’s administrator, Kathy Kleinfeld, had a choice to make – shut down, relocate or stay open and serve patients on either side of their abortion.
She decided to stay open as an abortion clinic that no longer provides abortions.
“It’s really important to us to continue to help in whatever way we can legally do so,” Kleinfeld said.
Sixty-six clinics across 15 states have closed in the wake of the Dobbs decision. Others have moved, or are planning to move, to states where abortion remains legal. According to INeedAnA, an online resource for abortion seekers, 32 former abortion clinics have remained open in states with bans to provide other services, such as birth control prescriptions, STI testing and gender-affirming care. Of those 32, just four, like Houston Women’s Reproductive Services, are providing pre-and-post abortion services, primarily for patients who travel out-of-state or who self-manage their abortions.
The services they offer include medical support, such as pregnancy tests and ultrasounds, and informational support, such as advice on how much bleeding is too much and how medication abortion works.
They also provide emotional support, “from the moment of the phone call where there’s sheer panic, and they don’t know what to do”, Kleinfeld said, “to the point where they come in and we watch their stress level just, step-by-step, get reduced”.
Kleinfeld, who has spent over two decades working for clinics in Texas, opened Houston Women’s Reproductive Services in 2019. In 2020, Covid broke out, and the Texas governor shut down abortion clinics for a month because he didn’t consider it “essential healthcare”. In 2021, another hit came when the state passed SB8, a law that in effect banned abortions at or around six weeks. And then came the Dobbs decision in June 2022.
With abortion fully banned in Texas, Kleinfeld found it painful to walk down the hall past the dark and empty rooms. She used to turn all the lights on, just to make it less depressing. It was expensive to pay for space they didn’t need, so the clinic sold most of its equipment and moved into a smaller facility in October.
Now, Houston Women’s Reproductive Services sees 170 patients a month. Half of them are seeking “aftercare” following out-of-state procedures or self-managed abortions with pills sourced online or through community networks. HWRS fields questions about symptoms like bleeding or nausea, confirms the pregnancy has ended with a follow-up ultrasound and provides referrals if necessary.
This comes with some risk, as Texas officials, in particular the state attorney general, Ken Paxton, have threatened to target people who help others access abortion. The state’s 2021 law SB8 criminalized the “aiding and abetting” of illegal abortion, and after the Dobbs decision, abortion funds in the state halted operations until they were sure that helping people access legal abortion out of state did not violate any laws. One man has sued his ex-wife’s friends for $1m each for allegedly supporting her efforts to obtain an abortion.
Kleinfeld said she was not concerned about prosecution because her clinic provides straightforward evaluation, counseling and referrals for legal options – and because they don’t ask too many questions.
“Some patients may choose self-managed care,” Kleinfeld said. “We don’t ask where or how they got their medications, we only ask when they took the pills. The rest does not matter.”
Patients are also vulnerable to legal risk. From a medical perspective, induced abortions are essentially the same as a spontaneous miscarriage, which means anyone experiencing pregnancy loss – regardless of the circumstances – can find themselves under suspicion.
The website of West Alabama Women’s Center (WAWC) – which provided abortions in Tuscaloosa before the Dobbs decision and now provides aftercare, among other services – explicitly states: “We will NOT ask questions to see if you may have instigated or attempted to initiate this miscarriage” and “We will also NOT do anything that would begin a potential investigation into your abortion.”
Robin Marty, WAWC’s administrator, said the clinic had to be strategic about how to continue supporting abortion patients while also complying with the state’s legal restrictions. Alabama’s attorney general has threatened to treat the act of helping someone get an abortion as a criminal conspiracy, so when patients ask where they can access abortion, the clinic directs them to a document on its website that lists its services and outlines patients’ options, alongside other resources, like adoption services and a Medicaid application.
Marty described a patient who had an abortion out-of-state, returned to Alabama and ran a fever. When she went to the hospital and said she had had an abortion, Marty recounted, the staff would not see her. She found her way to West Alabama Women’s Center, which prescribed her antibiotics to prevent sepsis.
In another case, an Alabama woman named Alison, who asked to go only by her first name, was six weeks pregnant when she started to bleed. Her OB/GYN found a blighted ovum, in which the gestational sac and placenta had formed, but there was no fetus. Standard treatments would have included a prescription for misoprostol, one of the two drugs used in medication abortion, or a dilation and curettage, which is a method of surgical abortion. But when Alison and her wife asked about next steps, the doctor apologized and said she couldn’t do anything. They had to wait to see if the miscarriage would pass on its own.
“I was pissed,” Alison said. “I didn’t want to keep going back and keep going back and [be] told there’s nothing we can do, yet – that we need to wait until your health is in serious danger.”
The next week, Alison made the two-hour drive to West Alabama Women’s Center to get an ultrasound to confirm the miscarriage was complete.
A growing desert for maternity care
But the mass closure of abortion clinics in red states means that dedicated aftercare providers are few and far between. There are 600 miles between Houston Women’s Reproductive Services and West Alabama Women’s Center, with no clinics left in Louisiana or Mississippi. What do exist in those gaps are anti-abortion centers, often called crisis pregnancy centers, which provide free pregnancy tests and ultrasounds and profess to counsel people on their options, but are primarily dedicated to steering them away from abortion.
Compounding the situation, rural areas are facing mass hospital closures and about 7 million women live in maternity care deserts, with low or no access to obstetric care. As a result, people seeking aftercare may end up in the emergency room because they’re not sure where else to go. According to Dr Bhavik Kumar, a family medicine physician and abortion provider with Planned Parenthood, that is far from ideal. Aside from long wait times and the risk of legal jeopardy, the rates of serious complications from abortion are vanishingly low, and going into an ER may subject a patient to treatments or interventions that aren’t appropriate.
“It’s very likely a patient would end up in a place that doesn’t provide the healthcare they need, but also face stigma and shame for their decision,” Kumar said.
Other groups are trying to bridge the gaps. There are abortion doulas, websites like Plan C and Women Help Women that connect people with information and resources, and underground community networks that support people throughout the abortion process.
The Miscarriage + Abortion Hotline receives 50 to 70 calls a day from people who are anxious they might need aftercare. “The vast majority of the time,” said its medical director, April Lockley, “the hotline provides reassurance to people that they don’t need to go for in-person care, but people deserve that if that’s their preference.”
While much of the energy on saving abortion rights in the US is focused on blue states, Marty wants people to recognize the need for the services that remain in states with bans. “Couldn’t we invest in the red state clinics that could try to stay open locally for people who did leave and came back, or who managed their own care, so we could keep people out of hospitals and out of jail?”
