Politics

The Most Unexpected Consequence of the Texas Abortion Ban

A positive pregnancy test is seen on the top bulb of an hourglass whose sand is almost completely at the bottom.
Illustration by Natalie Matthews-Ramo

In a third-floor medical suite with sweeping views of a Texas highway, staff members at Houston Women’s Reproductive Services are adapting to the new demands the state’s restrictive abortion law has placed on their jobs.

They try to schedule every patient for a visit on the same day she calls, lest that patient lose a single valuable day of the narrow window for care. They linger on the phone with frantic women who are already terrified that they’ll be forced to carry an unwanted pregnancy to term, even though they are just a day or two late on their period. And they have pivoted, in many cases, to dispensing emotional and logistical support instead of medical care.

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The clinicians are confronting novel reactions from patients, too. In addition to questions of spiraling desperation—how much time do I have? Why can’t you help me? Where do I go? How can I get there?—they are seeing an unprecedented outpouring of anguish. They have also noticed a troubling rise in feelings of regret.

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Because under the Texas law, people dealing with unplanned pregnancies have little time to consider their options: The law prohibits abortions—using the threat of expensive lawsuits brought by private bounty hunters—if they occur after the onset of fetal cardiac activity, which usually appears around four weeks after conception, in what health professionals call the sixth week of pregnancy.

But that doesn’t mean patients have six weeks of pregnancy to obtain a legal abortion. They have, roughly, one.

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It takes about five weeks for the first glimmer of a pregnancy, a gestational sac, to show up on a uterine ultrasound. About seven days after that, fetal cardiac cells begin moving in unison, at which point clinics like Houston Women’s Reproductive Services are no longer permitted to terminate the pregnancy. The week in between these two milestones is a precious, fast-closing window that patients can easily miss.

The timing is made even trickier by another Texas law that requires each patient to see the same doctor for two separate appointments, scheduled at least 24 hours apart, before terminating her pregnancy.

The average patient used to come to the office around the seventh or eighth week of pregnancy. Now, many patients are coming in so early that their pregnancies are undetectable by the ultrasound machine, even if their pregnancy tests come back positive. They are often distraught when told to return in a week for another ultrasound, especially if their work and family obligations would prevent them from traveling out of state if they miss their chance in Texas.

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“Women are peeing on sticks every day,” said Catalina Leaño, 51, the lead nurse at Houston Women’s Reproductive Services. “People are coming in in chaos and desperation, with this anxiety that you’re either too early or you’re too late.”

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Marjorie Eisen, 65, a patient counselor at the clinic, said, “Every time the doctor and the technicians go into a room to do an ultrasound with the patient, everybody’s holding their breath—just hoping we’re not going to get cardiac activity.”

A single day can make the difference between a simple set of pills taken at home and the expensive, stressful, and time-consuming process of seeking an abortion out of state. The only other legal option is state-mandated childbirth.

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The women who work at the Houston clinic are diverse in age and life experience, but they share a sense of purpose that drives their work. Many entered abortion care as clinic volunteers, drawn in by the prospect of helping women live full, independent lives; some, like Eisen, have worked in the field for 30 years or more. If they didn’t feel personally invested in abortion rights, the staff members told me, they wouldn’t show up every day to persevere in a medical practice the state is actively trying to obstruct. Several employees expressed gratitude for the abortions they were able to get when they were younger, which allowed them to pursue parenthood, education, and career paths on their own terms.

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So it came as a demoralizing shock when the staff began noticing how the Texas law, also known as S.B. 8, filled some of their patients with frantic uncertainty.

Since it opened in 2019, Houston Women’s Reproductive Services has provided one single medical service: medication abortion. So in previous years, the vast majority of patients had already arrived at the decision to get an abortion when they made their initial appointments.

Now, about once a week, a patient won’t show up for her second appointment. Or she’ll come to the clinic for that second visit, seemingly ready to pick up her medication, and then leave without it. Sometimes, women will go home without the pills and call later that same day, having changed their minds again, and ask if there’s still time to come back. Occasionally, a patient who rushed to get an abortion will contact the clinic later to express feelings of ambivalence or remorse.

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“They frequently tell us, ‘I just don’t feel like I’ve had enough time to think about this,’ ” Eisen said of patients. The legislators who passed the ban claimed to want Texans to have fewer abortions, “but in fact, in some ways, we think it’s rushing people.”

In other words, the restrictive nature of the law does more than hamper a patient’s access to abortion. It distorts her decision-making process.

According to several studies, abortion regret is remarkably uncommon. In one study of 667 women who’d had abortions, 84 percent said they had only positive feelings or none at all about the abortion they’d had five years ago. Though 54 percent of the participants said the decision was very or somewhat difficult to make, over 95 percent said it was the right decision for them.

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Other studies have found that the vast majority of patients believe their abortions did them more good than harm, that having an abortion does not increase a patient’s risk for depression or anxiety, and that the level of uncertainty patients experience in deciding to terminate a pregnancy is comparable to or significantly lower than for other health care decisions.

In Houston, when people had more time to process the news of their pregnancies, they’d usually arrive at the clinic secure in their choice. Maybe they’d already spent a couple of days envisioning how having a child—often, a third or fourth child—would change their life’s trajectory, or talked through their options with a partner, parent, or trusted friend.

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Now, the counselors at Houston Women’s Reproductive Services say they’ve never seen so many patients struggling with indecision and self-doubt.

“That has been, I think, the cruelest aspect of this law,” said Jeana Nam, 27, who works there as a counselor. “A ticking time bomb takes a feeling of control away from the pregnant person.”

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For many other patients, the decision remains clear. One 24-year-old woman who visited the clinic in April told me that she knew right away what she needed to do when she learned she was pregnant. “I have three kids right now. My youngest is 6 months, and my oldest is 4,” she said. “Right now just isn’t the time to have another one.”

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On a Wednesday in April, I sat in the backroom of the clinic while Eisen and Nam answered calls from women seeking care. One patient, whom I’ll call Rebecca, told Nam she’d tested negative on several pregnancy tests but was sure they were wrong. Her normally regular period was six days late. “You can come in for an ultrasound, but it’s really unlikely that we’re going to see something if your tests are negative,” Nam told her. “I don’t want you to waste your $100.”

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Rebecca had recently moved to Texas and didn’t have health insurance or a primary care doctor to see about a late period. She insisted on making an appointment for later that day. Nam gave her a time slot and hung up the phone. “She was like, ‘Because of this law, I’m freaking out,’ ” Nam said. “Maybe seeing an empty uterus on her ultrasound will give her peace of mind.”

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In between calls, staffers spoke about the patients who, due to tight scheduling, the abortion ban’s cruel precision, and the unpredictable snafus of everyday life, had missed their window of opportunity. One woman had a late period but a negative at-home pregnancy test; her clinician at Houston Women’s Reproductive Services advised her to take another test in a week. Three weeks later, when the patient remembered to take her second test, she was positive. She hurried into the clinic for an ultrasound, but she was already too far along to receive the abortion she wanted.

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To advise patients on timing, Leaño makes careful note of the details in each ultrasound image. If there’s a yolk sac within the gestational sac, “the fetus will start to sprout from that in about a day or two. And then within a day, the cardiac cells start beating together,” Leaño said. “So I tell the patient, ‘You’re super early. But because of this ridiculous law, you really have a day or two to come back. Because by the third or fourth day, I cannot guarantee you there’s not going to be a heartbeat.’ ”

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The clinicians say they always tell patients that if they’re not sure if they want to terminate a pregnancy, it’s better to wait until they’re ready, even if that means seeking care out of state. But they also can’t pinpoint with exact certainty when any given pregnancy will cross the legal threshold for termination. “I mean, this is a biological process,” Leaño said. “All I can do is go by intuition. And that doesn’t give women enough time to think about it. So they’re making a rush decision, and that’s when regret comes.”

Kathy Kleinfeld, the clinic’s administrator and founder, typically exudes calm competence and good cheer, but grew angry when I broached this consequence of the law. “It’s pretty ironic, because Texas is a state that said, ‘Oh, wait, you need to take 24 hours. You need to have your ultrasound, then go home and think about it, because we want you to be sure,’ ” she said. “All this pressure on, ‘We want you to be sure of your decision before you go through with this.’ And then they institute a six-week ban, which essentially gives women just a matter of days to find out they’re pregnant, make a decision, get an appointment, and go through with it. So which one is it? Does the state really want women to take more time and think about it? No. They just want to control women.”

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When the law first went into effect, employees at Houston Women’s Reproductive Services would direct patients who could no longer get an abortion in Texas to an online directory of abortion providers around the country, filtered by distance and ability to care for patients at various points in pregnancy.

But they found that many patients were often too deep in a state of shock at being turned away—multiple employees described the typical reaction as a “deer in the headlights” look—to absorb a generic recommendation. So workers began asking a series of questions to help narrow down a patient’s options. (Can you drive, or do you have the ability to fly? Do you know somebody in another state who can help you? Does anyone else know you need an abortion—and might they have a cousin or an aunt you can stay with?) They also give patients a handout that lists a hotline for financial assistance and contact information for clinics in Tulsa, Denver, and Fort Lauderdale that Kleinfeld knows and trusts.

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The nearest out-of-state clinics are in Louisiana, but for most patients who cannot fly, Oklahoma is a better option. Louisiana abortion providers, now inundated with Texas patients, are booking appointments several weeks out, and a state law requires patients to appear for two in-person visits 24 hours apart. (As another indication of the total collapse of abortion-access infrastructure in the South, Houston Women’s Reproductive Services now frequently sees early-pregnancy patients who’ve traveled to the clinic from Louisiana, even with the Texas ban, because they were able to get an earlier appointment there than they could get in Louisiana.) Oklahoma has a similar law, but the first appointment can be performed by phone, which makes it possible for Texans to complete the round-trip journey in a single (grueling) day. More Texans have gone to Oklahoma for abortions in recent months than any other state.

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But that option may soon be eliminated. Earlier this month, Oklahoma Gov. Kevin Stitt signed a law that will criminalize all abortions, save those provided to save a pregnant person’s life, when it goes into effect in August. The Oklahoma House has also passed a separate bill that applies the novel legal workaround of the Texas law—the private-bounty-hunter enforcement method, which has allowed the law to remain in effect even as it is challenged in court—to a ban on all abortions. If the bill passes the state Senate, it will take effect as soon as Stitt signs it.

The option of traveling out of state at all already feels like an impossibility to some pregnant Texans. “They beg us, you know, ‘I cannot go to another state. My parents don’t know.’ ‘My husband will kill me.’ ‘I don’t have the money. My kids depend on me. I’m the only breadwinner,’ ” Leaño said regarding the clinic’s patients. “It just tears you apart.”

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Viewed through one lens, the rush of people keeping close track of their cycles and catching their pregnancies early shows determination and resilience. “It does speak to women’s resourcefulness,” Kleinfeld said. “We know that women will always obtain services they need. History has shown that again and again. This is just one more example of how these laws make it harder, but people who have the resources and the wherewithal and the knowhow can get it done and do get it done.”

But that resourcefulness can also be understood as a distress signal from a terrorized population whose reproductive capacity has been seized by the state.

The suffering abortion providers are witnessing in Texas points to a looming domestic human rights crisis on the horizon: a rapid disintegration of the reproductive health care infrastructure that has saved the lives of countless patients—and dramatically improved the physical, mental, and economic outlooks of entire generations of women—in the decades since Roe v. Wade was decided.

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A tidal wave of anti-abortion legislation is making its way through state courts, part of an effort to prod the Supreme Court into weakening or overturning Roe. If it does, the costs will compound over decades, as women are criminalized and consigned to poverty for lack of access to legal abortion.

For now, Kleinfeld maintains a spreadsheet of all the patients the clinic has seen for ultrasounds and, upon the detection of fetal cardiac activity, been forced to turn away. It’s more than 200 names long and excludes the thousands of people who learned by phone, while trying to make an appointment, that their pregnancies were too advanced to receive care in Texas. Unless these patients come back to the Houston clinic for follow-up care, Kleinfeld never learns how they fared. Another abortion provider in town told Kleinfeld she’d started calling and texting such patients to check in but had trouble reaching them. She soon realized they probably didn’t want a reminder of their predicament from someone who couldn’t help.

Leaño still thinks about one panic-stricken woman who begged her to make an exception to the rule. The patient said that, a little over a month earlier, she had awoken, disoriented, in a strange hotel room; she believed someone had drugged her drink. She wasn’t on birth control because she wasn’t sexually active. That day, at the clinic, Leaño performed an ultrasound that revealed the movement of fetal cardiac cells. She had to send the patient away.

Weeks later, Leaño considered contacting the patient to check in, but stopped herself. “When you are an abortion provider, you want to check on somebody, but I don’t want to remind them of this place, or that moment in their lives,” Leaño said. “I wonder, and I carry them with me, you know? But it’s just—I cannot reach out. Because I don’t want them to remember this.”

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