As state legislators continue to pen bills that restrict abortion access and penalize those who perform abortions, clinical and at-home abortion providers renew their fight for the right to provide and receive an abortion and the people most affected by such laws.
Dr. Raegan McDonald is the CEO of Power to Decide, an organization that empowers people with access to contraceptives to prevent unwanted pregnancy and information and sexual health resources, according to its website. McDonald is also an obstetric and gynecologic physician who’s provided pregnancy and abortion care for nearly 20 years.
McDonald said the consequences of delaying or being denied an abortion can affect the life trajectory of those unable to obtain abortions and children from unwanted pregnancies.
“People who are unable to get the abortion care that they need are much more likely to live under the Federal Poverty Level compared to people who were able to get abortions that they wanted. Those people are more likely to continue to be in abusive relationships and to report anxiety and lower self esteem again, compared to people who were able to get abortions that they wanted,” McDonald said in a Zoom call. “The consequences also extend to the children of that unwanted pregnancy as well as for the existing children of the family.”
She said restrictive abortion laws including Texas State Bill 8 (SB8) can have grim consequences.
Texas enacted SB8, also known as the Texas Heartbeat Act, on Sept. 1. The bill, signed into law by Texas Gov. Greg Abott in May, restricts abortions after fetal cardiac activity is detected, usually at six weeks, and allows any citizen to sue a person who performs or induces an abortion or aids and abets the performance of an abortion for a minimum of $10,000 plus legal fees.
Though the bill doesn’t criminalize performing or receiving an abortion after six weeks, it opens doctors and abortion care providers to lawsuits that can be brought against them by anyone except patients for whom they provided a consented abortion or anyone who impregnated someone receiving an abortion through rape or incest, according to the abortion law.
People who don’t reside in the state of Texas can sue an abortion provider or anyone who aided or abeted an abortion provider.
“The impact of the law on people's short and long term wellbeing is nothing short of catastrophic,” McDonald said.
Restriction consequences
She said she saw these catastrophic results firsthand as she witnessed the death of a woman who was unable to access a safe abortion when she traveled as a college student in El Salvador, which has restrictive abortion laws.
“I saw a woman who died from lack of access to safe abortion services,which impacted me greatly, obviously, and put me on this pathway to dedicate my life to ensuring that people have access to services and care,” McDonald said.
The U.S. Department of Justice announced it had filed a lawsuit to prevent the state of Texas from enacting SB8, according to a Sept. 9 statement on the department’s website.
The bill shifts law enforcement from the executive branch to citizens who serve as “bounty hunters,” who get $10,000 for reporting those who aid “a woman’s exercise of her own constitutional right,” the Justice Department said in the statement.
The department’s complaint alleged the new law allowed Texas to effectively outlaw abortion while evading responsibility for violating the constitution.
SB8 makes no exceptions for cases in which a person was impregnated through rape or incest and only allows for abortions after six weeks if the health of a pregnant person is in jeopardy.
Legislators crossed out the word fetus in SB8 and replaced it with the phrase “unborn child” and also required that a sonogram, photographic imaging that shows the fetus, and description of the fetus’s cardiac activity, size, health and presence of limbs must be provided to the patient prior to a procedure being performed.
Procedure safety
McDonald said abortion as an outpatient procedure is not high risk as nearly 40% of abortion recipients in the U.S. have opted for a medicinally induced abortion rather than an abortion procedure in the last year.
But the abortion procedure remains “about as safe as a colonoscopy,” according to a Oct. 9 article from The ACLU Texas.
“Abortion is extremely safe, it has one of the lowest complication rates of all outpatient procedures but it's simply unjust to put unnecessary roadblocks and barriers in between people, their families and carers,” McDonald said.
She also said at the six-week mark, at which cardiac activity is normally detected, most people don’t know they’re pregnant.
“It's important to note that many people don't even know that they're pregnant, you know, by the time six weeks passes, right, like we sort of count and track pregnancies by your last menstrual period,” McDonald said.
The underground
An at-home abortion provider, who prefered to go by the alias Kaya for privacy concerns because her work has been criminalized, said the ability of ordinary citizens to civilly prosecute abortion providers is the SB8’s most disturbing aspect.
“It creates this sort of atmosphere of vigilante finger-pointing,” she said in a Zoom call. “It's just like the witch hunts in Europe.”
Kaya’s part of a California network of underground abortion providers.
Her colleagues and their clients operate in a “triangle of trust” in which she said is threatened when fear of prosecution enters into conversations about guiding someone through an abortion.
“People are reassessing themselves and people are taking risks and others are scared,” Kaya said. “I mean, we're all scared, I should say.”
Kaya said because SB8 doesn’t criminalize or control traveling out of state to provide or receive an abortion, those with the means and ability to travel will be able to receive an abortion while those with disabilities, living below the poverty line, lack resources or support because of language barriers or experience isolation from domestic abuse will face challenges.
“Let’s be really, really, really clear: rich folks in Texas will always have access to abortion,” Kaya said. “They’ll hop on a plane and come to California, they’ll hop on a plane and go to wherever. It’s people living in poverty that are going to be affected and we’re going to see them die at higher rates.”
She said in addition to being concerned about how restricted abortion access will affect Black, brown, non-English speaking, immigrant and underage people, she worries about gender-diverse individuals who already face discrimination in the healthcare system.
“[Transgender] people do not have access to healthy or to good care because most of our providers haven't been educated in how to care for a masculine-presenting person who has a uterus,” Kaya said. “They won't even get their pronouns right, let alone give them competent care.”
“Pro-life” vs. “Pro-choice” rhetoric
Much of the rhetoric surrounding abortion is presented in a way that is divorced from medical terminology. Instead, McDonald said, it frames abortion not as a medical procedure but as one side in opposing “pro-life” or “pro-choice” ideologies.
Framing abortion in this way is problematic because it doesn’t acknowledge the complexities surrounding abortion in people’s lives, McDonald said.
“There aren't women who have abortions and women who have babies but people that might need different types of care throughout their reproductive life,” she said.
In addition to creating a false dichotomy, which turns abortion from a medical procedure into a moral dilemma, the “pro-life” and “pro-choice” narratives surrounding the abortion debate create a framework of who deserves an abortion, McDonald said.
“We shouldn't stigmatize one aspect of that care or have a hierarchy of pregnancies, of good pregnancies and bad pregnancies or good choices or bad choices,” McDonald said. “This is the life course of people capable of reproduction.”
She said the pro-life rhetoric surrounding restrictive legislation such as SB8 doesn’t take into account that preventing abortion contributes to high maternal mortality.
Texas’ maternal mortality rate is higher than the national average with 18.5 deaths per 100,000 births, according to a May 2021 article by The Guardian.
“It's not about promoting life or improving people's life or health at all,” McDonald said.
She said rather than speculate on why Texas legislators continue to restrict abortion, she preferred to focus on the clear detrimental outcomes to undercutting public health by restricting abortion and denying proper care to parents and infants.
“We need to invest in support and comprehensive reproductive health care including safe legal abortion, which the data clearly shows is associated with better maternal and infant health outcomes,” McDonald said.
Texas’ racial disparity in maternal mortality is also extreme as Black women in Texas are more likely to die from complications related to childbirth than any other race and account for 11% of live births but 31% of maternal deaths, according to a September 2020 state report.
Decolonizing birth and abortion
Kaya said she wants to see more emphasis placed on decolonization of abortion practices with more power and agency being placed in the hands of Black and brown gynecologists, midwives and abortion care providers.
She said moving midwifery and abortion care back into the home environment and divorcing this care from corporate medical establishments would empower those providing and seeking abortions.
She noted that modern obstetrics and gynecology are rooted in the research and teachings of J. Marion Sims, who performed experiments on enslaved women without the use of anesthesia. Prior to J. Marion Sims and the reformation of healthcare as an industry, midwives and healers prevented pregnancy implantation and performed abortion in addition to assisting with births.
“I want to see more Black and brown people succeed in that career because they are shifting this narrative,” Kaya said. “They're pushing the boundaries of what medicine looks like in the U.S.”
Kaya said as a person of mixed Indigenous and European heritage herself, she performs at-home abortions as part of her connection with her lineage and seeks to bring back the long-held traditions that were stripped from Black and Indigenous midwives when obstetrics and gynecology became heavily regulated and commercialized.
She said funding smaller collectives of birth workers and abortion providers can address many of the systemic issues in the abortion care system.
Kaya said while Planned Parenthood has access to more funding, smaller collectives need financial assistance to reach marginalized individuals and people living in rural areas.
“Fund the people who are looking at things intersectionally or holistically because they're the ones who are going to have a bigger picture of how to fix this,” Kaya said. “Because they're the ones who are living it.”
McDonald also stressed the importance of voting to keep abortion accessible.
“We need to make sure that we're voting for lawmakers who are aligned with providing high quality care to people regardless of their decisions and choices with their pregnancies,” McDonald said. “We need to encourage, at the federal level, Congress to pass laws like the Women's Health Protection Act that would prevent states like Texas from enacting these undue restrictions for unnecessary restrictions to for abortion care.”
The future
Though they perform abortions and care for patients in different systems, both Kaya and McDonald said they look forward to a day when providing and receiving abortions is safe, easily accessible and entirely legal.
“I dream of a day when we can really center the experiences of people where people don't feel shame and stigma and that when they feel fully supported in their decisions,” McDonald said.
Kaya emphasized the U.S. needs to be completely changed systemically for that to happen.
She said the denial of people’s agency over their bodies is directly connected to capitalism, the colonization of people’s land and the destruction of lives and livelihoods.
“My prayer is that we all are able to do that in ways that are responsible and are less focused on white supremacy and making money and more focused on having healthy lives and helping healthy ecosystems. our bodies are microcosms of what's happening on a global level,” Kaya said.
She said though it has risks, she’s invested in the work she does because it’s connected to her values.
“Everything that we do in this world, whether it's fighting to take down the wall, whether it's fighting for immigrant rights, whether it's tearing down our prison industrial complex, whatever it is, that all ties to abortion,” Kaya said. “When you ask me ‘Why do I do this work?’ I do this work because we as humans deserve to be witnessed. We deserve to heal and to have the ugliest parts of ourselves crack open.”
