Anti-choice activists may have a better shot than you think at getting the Supreme Court to revisit Roe v. Wade under Donald Trump. (Photo by ZACH GIBSON/AFP/Getty Images)
A series of court battles over onerous reproductive rights restrictions in one conservative state could help right-wing activists challenge ‘Roe v. Wade.’
When Donald Trump ran for president, despite his long history of pro-choice positions, he essentially offered evangelical Christians a deal: Help elect me, and I will appoint pro-life, conservative justices to the Supreme Court. Sure enough, less than three months into his presidency, Trump’s first SCOTUS appointee—Neil Gorsuch—was confirmed, and anti-choice advocates seemed to be one step closer to their ultimate goal of overturning Roe v. Wade.
It may take another appointee to truly tilt the scales of justice against reproductive rights in America’s highest court. But in the meantime, conservatives have been eyeing the Eighth Circuit Court of Appeals, based in St. Louis, Missouri, as a vehicle to bring such a challenge. That’s where, in 2015, appellate judges urged the nation’s highest court to revisit existing abortion jurisprudence, and turn matters over to the states, as conservatives have long dreamed.
Now that same federal appeals court, which may be more hostile than any other to abortion rights, is getting a bunch of new opportunities to go after a woman’s right to choose in Arkansas—and maybe even set the stage for the end of Roenationally.
Over the past several years, legislators in Arkansas—one of seven states under the Eighth Circuit’s purview—have passed some of America’s most restrictive abortion laws. Already in 2017, Arkansas passed a statute that would criminalize doctors who perform dilation and evacuation (the most common second-trimester procedure), and also permit husbands to sue to prevent their wives from obtaining abortions—with no exceptions even for rape or incest.
Set to go into effect on July 30, the law was blocked after the American Civil Liberties Union, the ACLU of Arkansas, and the Center for Reproductive Rights sued over it and three other recently passed abortion restrictions. Lawyers brought the suit on behalf of a physician working at one of the last two abortion clinics in the state, and argued the laws posed unconstitutional burdens on a woman’s right to choose.
On July 28, federal judge Kristine Baker blocked the laws’ enforcement, and Arkansas Attorney General Leslie Rutledge filed for an appeal two weeks ago. A spokesman for the AG did not return multiple requests for comment.
What should worry abortion-rights advocates is that there’s plenty of reason to suspect the Eighth Circuit will be sympathetic to Rutledge’s challenge. In March 2016, Judge Baker issued another injunction against a 2015 Arkansas lawrequiring physicians who prescribe abortion-inducing drugs to secure contracts with doctors with hospital-admitting privileges—a high bar to meet in the increasingly conservative state, and one the American College of Obstetricians and Gynecologists and the American Medical Association said had no medical basis. This past July, the Eighth Circuit lifted Baker’s injunction, ruling she would need to more concretely prove that a sizable number of women will face harm under that law.
In an interview with VICE, Steve Aden, chief legal officer and general counsel for Americans United for Life, said he felt the Eighth Circuit’s request for “some real math” was reasonable. He also defended the admitting privileges requirement as a common-sense measure to protect women’s health, noting that other outpatient surgical procedures generally require it. “If you or I go to a clinic and get Lasik or a colonoscopy, chances are really good that the doctors will have admitting privileges,” he said.
Meanwhile, the US Supreme Court last year heard arguments for Whole Woman’s Health v. Hellerstedt, widely considered to be the most significant reproductive rights case in nearly 25 years. In a 5–3 decision, the justices ruled that a package of Texas abortion restrictions imposed an unconstitutional burden on women seeking to end their pregnancies.
Fatima Goss Graves, the president and CEO of the National Women’s Law Center, told VICE anti-abortion opponents haven’t been much deterred by that outcome. On the contrary, she said, they are eagerly working to put more abortion cases before the Supreme Court as soon as possible. “They are still purposely trying to pass extreme laws that conflict with Whole Women’s Health, with Roe, so they’ll [then] be challenged in court,” she said. “That is the strategy.”
Another Arkansas case that could reach the Supreme Court concerns conservative boogeyman Planned Parenthood. In 2015, following the release of doctored videos purporting to show Planned Parenthood illegally profiting from the sale of fetal tissue, Arkansas Republican governor Asa Hutchinson announcedhe would be terminating Medicaid contracts with the women’s health organization. Judge Baker blocked the move that September, but last month, a three-person panel on the Eighth Circuit decided Arkansas could cancel its Medicaid contract with Planned Parenthood—a notable departure from rulings in the Fifth, Seventh, and Ninth Circuits. On August 30, the plaintiffs appealed to make their case again before the entire Eighth Circuit.
Aden, of Americans United for Life, thinks this case stands a shot of reaching the Supreme Court given the Eighth Circuit’s first decision diverged so sharply from other Appeals Courts nationwide.
I asked Bonyen Lee-Gilmore, a spokesperson for Planned Parenthood Great Plains (an affiliate overseeing Arkansas, Kansas, Missouri, and Oklahoma), if they would appeal to the Supreme Court, should the full Eighth Circuit uphold the Medicaid ruling. “When it comes to next steps in the legal world, we really play it one step at a time,” she said. “Every time a decision comes down, we’re evaluating all our legal options, and the reality is we could end up in the Supreme Court, but we’re not there yet. Right now, we’re just seeing if we can successfully secure an en banc appeal.” (To hear a case ‘en banc’ means before the entire bench of judges, rather than a three-person panel.)
It’s worth noting that even though Arkansas’s governor cancelled state Medicaid contracts with Planned Parenthood over the 2015 fetal tissue videos, three Republican-led congressional investigations and 13 state-level probes—including one by a Texas grand jury—found no evidence of wrongdoing.
Gillian Metzger, the Stanley H. Fuld Professor of Law and vice dean at Columbia Law School, thinks the Eighth Circuit “has really pushed the envelope” on constitutional retraction of reproductive rights in America. But whether these specific cases make it to the Supreme Court, she said, comes down—as always—to how willing justices are to engage with the abortion issue again. “The bigger question is does the Court have an appetite for this after 2016? And my guess it might wait a little bit to see how the Whole Women’s Health decision plays out,” she said.
In the meantime, President Trump will have the opportunity to fill three vacancies on the Eighth Circuit. If all are confirmed, according to longtime legal writer Rox Laird, only one of the Eighth Circuit’s 11 judges will have been appointed by a Democratic president, making it “the most ideologically lopsided of all the US Court of Appeals.”
Even if pro-choice advocates secure Medicaid funding for Planned Parenthood and defeat this round of abortion restrictions in the Eighth Circuit—by no means a safe bet—advocates aren’t expecting legislators to slow down their anti-abortion efforts anytime soon. In mid August, Planned Parenthood Great Plains and the ACLU argued yet another case in Arkansas federal court, protesting a law mandating the suspension of an abortion provider’s license for any minor error found during an inspection. That rule doesn’t apply to any other licensed health center in the state.
“We’ll be on high alert when the legislature returns in 2019 and continue to fight these extreme attacks on women and their rights,” said Rita Sklar, the executive director of the ACLU of Arkansas. “Often, the only way to get Arkansas politicians out of the exam room is to take them to court.”
The statistics aren’t good. According to recent estimates, women make up just under 20 percent of Congress and less than 25 percent of all state legislatures. Only six of our nation’s governors are women. But we are 51 percent of the population. And the research shows that when women participate in government, we make it run better, more collaboratively. Historically, women have needed to be convinced to enter politics. But within weeks of the 2016 presidential election, thousands of women announced they plan to run. And we want them to win. So we’re giving them a weekly example of a woman who has run and won — or in this week’s case, a woman who’s well on her way. The point: You can, too.
Kate Brown is the current Governor of Oregon. Previously, she was the Oregon Secretary of State and in the Oregon State Senate. She succeeded former Governor John Kitzhaber when he resigned in February 2015 and won her own special election in 2016, making her the first openly bisexual governor ever to serve in the United States. Since Trump was inaugurated, Oregon has codified a woman’s right to choose, just in case the Supreme Court overturns Roe v. Wade and has passed protections against deportations. Brown herself has issued an executive order to reaffirm Oregon’s commitment to immigrants, strengthening its status as a sanctuary state and defying Trump’s hardline positions. Last month, she signed the Reproductive Health Equity Act into law The measure requires all insurers to cover birth control and abortion — without a copay. It has been widely deemed the most progressive reproductive health policy in the country.
I remember telling my mother in the third grade that I wanted to be President of the United States. I remember her saying, “But we don’t have enough money.” It wasn’t that I was raised in a low-income home. It was more, I think, “You’re not the right type of person that runs for president.” It seemed like her way of telling me, “That’s not a job that girls do.”
Growing up, I was a 1960s baby in Minnesota, and books were my sort of portal to the world. I read extensively and read about a lot of really strong women, like Amelia Earhart and Julia Gordon Low, who founded the Girl Scouts, and of course Harriet Tubman. Back then, my teachers were really important for me; they were role models, pushing me and encouraging me to succeed. And that continued throughout my undergraduate classes at the University of Colorado and in law school in Oregon.
I had always wanted to go to law school because I knew that being a lawyer would give me the tools to fight for justice and equality, and later, I got into public service because I wanted to be a voice for the voiceless. So, in 1982, I moved to Oregon to go to law school. While I was there, one of my biggest mentors in law school was the associate dean, and she happened to mentor another woman in the class before me, whose name you probably know, [North Dakota Sen.] Heidi Heitkamp. The fact that she mentored both Heidi and me is pretty extraordinary, I must say.
On her “from birth” feminism
At Lewis and Clark [Law School], I really fell in love with Oregon. It was like I came home. I’d been somewhat active in high school, not so active in college; I was quite active here when I was in law school, working and volunteering at one of the local women’s health centers. This is when we were having the battle of making sure women could get into health clinics without being harassed by protestors. After law school, I continued my activism, both through volunteering and getting involved working [to oppose] some of the anti-choice ballot measures.
A review by Rewire found that at least $3.1 million in grants have been awarded to religiously affiliated organizations or crisis pregnancy centers, also known as fake clinics.
The grants for abstinence-only sex education programs come in the wake of the Trump administration’s decision to eliminate $213.6 million in grants for teen pregnancy prevention programs and research. Ron Sachs-Pool/Getty Images
Religious imposition laws are designed to shield private individuals and businesses from complying with nondiscrimination laws based on a religious objection to that service.
The Trump administration in recent weeks has awarded millions in grants to state governments and organizations to fund abstinence-only sex education. More than $3 million in federal funds has gone to organizations that distribute inaccurate and misleading information about sexual health.
The U.S. Department of Health and Human Services (HHS) awarded $8.9 million in grants to 21 organizations and agencies through the Competitive Abstinence Education (CAE) program. HHS has awarded an additional $2.1 million in grants and sub-grants to 34 organizations and agencies through the abstinence education program created by the Affordable Care Act (ACA).
The grants for abstinence-only sex education programs come in the wake of the Trump administration’s decision to eliminate $213.6 million in grants for teen pregnancy prevention programs and research.
A review of the abstinence education grants by Rewire found that at least $3.1 million has been awarded to religiously affiliated organizations and crisis pregnancy centers, or fake clinics that use anti-choice propaganda to dissuade people from seeking abortion care.
ThriVe was awarded a $433,021 grant to provide abstinence-only education to youth in the St. Louis area. The organization operates three fake clinics in the St. Louis area, and has regularly organized protests of Planned Parenthood. ThriVe’s Best Choice abstinence-only program has faced criticism from parents, and several school districts in the St. Louis area have discontinued or suspended the program to review the curriculum.
Pamela Merritt, executive director of Reproaction, told Rewire in an email that the Trump administration’s grant to ThriVe is “outrageous.”
“Missouri is already one of seven states rerouting millions in federal TANF dollars intended to alleviate hunger to these fake clinics,” Merritt said. “The state’s best interests are not well served by Trump sending even more hard-earned tax dollars to a controversial anti-abortion fake clinic that systematically misleads and shames women seeking abortion care.”
“Abstinence-only programs and crisis pregnancy centers commit a sin of omission when they deny real facts to students and families. Taxpayers do not want their money to go to anti-abortion groups that lie to women and girls,” NARAL Pro-Choice Ohio Executive Director Kellie Copeland said in a statement. “These funds are desperately needed in our communities, but they have to get to real health care organizations and groups that provide comprehensive sex education classes. Abstinence-only programs are not effective at delaying the initiation of sexual activity or in reducing teen pregnancy. They’re a harmful waste of taxpayer dollars. Period.”
Other religiously affiliated or anti-choice organizations awarded CAE grants were Bethany Christian Services, which received $441,577; Ambassadors for Christ Youth Ministries, awarded $442,019; and Trinity Church, which received a $442,019 grant.
Three religiously affiliated organizations were awarded sub-grants as part of the ACA’s abstinence education grant to the New Jersey Department of Health. Mount Olives Church of God was awarded $263,236; Free Teens USA was awarded $306,164; and Lifeguard Inc received $343,144.
In a growing number of reproductive health care deserts, there’s no place to get an abortion — or give birth.
A pregnant woman in McAllen, Texas in August, 2016. A pregnant woman in McAllen, Texas in August, 2016.
The last abortion clinic in Kentucky is fighting to stay open.
A trial that began on Wednesday at a federal court in Louisville will decide whether EMW Women’s Surgical Center can continue to provide abortions. Kentucky’s Republican Gov. Matt Bevin told the clinic in March that its agreement to comply with strict laws targeting abortion clinics was inadequate, according to NPR. The center sued, arguing that the notification came “out of the blue.” If it wins, the case could open the door for other Kentucky clinics to provide abortions. If it loses, the state will become the first one with no place to safely terminate a pregnancy.
The number of abortion clinics nationwide declined 6 percent between 2011 and 2014, with the biggest declines happening in the Midwest and the South, according to the Guttmacher Institute.
Not only are abortion clinics like the one in Kentucky under threat, but a new study shows that hospitals in rural areas throughout the country are eliminating obstetric services, meaning women have to drive for hours to give birth.
The study found that 54 percent of rural counties had no hospital with obstetric services in 2014, up from 45 percent in 2004, according to a recent study published in the journal Health Affairs and reported at ProPublica. That left 2.4 million women of reproductive age living in counties without obstetric care. In Kentucky, where the fight over the last abortion clinic is taking place, only34.1 percent of rural counties had a hospital with obstetric services, down from 40 percent in 2004.
The Kentucky clinic’s struggle and the study’s findings point to a dual crisis in reproductive health care: Whether a woman wants to continue with her pregnancy or end it, in more and more parts of the country, there’s nobody to help her.
Having to travel long distances for abortion or maternity care is bad for women and families
When the nearest abortion clinic is far away, the costs of the procedure for women go up. In addition to the cost of gas or train or bus tickets, women may have to pay for lodging, especially in states that require multiple clinic visits for abortions. They may also have to take time off work, which can mean lost wages or even a lost job. The need to save money for travel expenses can force women to delay their abortions, making them even more expensive.
When travel becomes prohibitively expensive or difficult, women may try to self-induce an abortion. In Texas, where 96 percent of counties have no abortion provider, between 100,000 and 240,000 women between the ages of 18 and 49 have tried to self-induce an abortion at some point in their lives, according to a 2015 estimate by the Texas Policy Evaluation Project. Depending on the method, self-induction can be dangerous — in a 2014 survey reported by CBS, some women reported getting hit in the stomach in an effort to end a pregnancy.
Having to travel long distances for obstetric care can also be dangerous. Long travel times could contribute to infant mortality and pregnancy complications, according to the Health Affairs study. “All maternal and infant deaths are tragic,” the authors write; “those related to impaired access to care are abhorrent.”
Pregnancy and childbirth come with a number of risks, including hemorrhaging, gestational diabetes, and postpartum depression, said Megan Donovan, a senior policy manager at the Guttmacher Institute. “Access to quality prenatal, labor and delivery, and postpartum care is essential to help identify and avoid these dangers.”
When patients live far away from their obstetricians, prenatal care often has to focus on travel and other logistical planning for the birth, rather than the health of the mother or fetus, said Katy B. Kozhimannil, a professor of health policy and one of the study authors. “There’s a level of anxiety” around giving birth for anyone, she said. Living in a rural area where just getting to the hospital is a struggle only heightens that anxiety.
Why are women losing access to abortion and maternity care?
Some of the biggest drivers of abortion clinic closures are targeted regulation of abortion providers, or TRAP, laws. These laws place restrictions on clinics that do nothing to protect patients. In 11 states, for instance, clinics are required to have a relationship with a local hospital — according to the Guttmacher Institute, such laws do nothing to help patients, but give hospitals “effective veto power over whether an abortion provider can exist.” Kentucky passed such a law in 1998, requiring abortion doctors to have transfer agreements with hospitals; Gov. Bevin now argues that EMW’s transfer agreement is inadequate.
In Whole Woman’s Health v. Hellerstedt, last year, the Supreme Court found that a Texas law requiring that abortion providers have admitting privileges at local hospitals, and that abortion clinics be certified as “ambulatory surgery centers,” constituted “an undue burden on abortion access” and was unconstitutional. The majority opinion, by Justice Stephen Breyer, said that neither provision of the law “offers medical benefits sufficient to justify the burdens upon access that each imposes.”
Reproductive rights advocates saw the decision as a serious blow to the TRAP law strategy. The American Civil Liberties Union, which is representing EMW Women’s Surgical Center, believes that the Kentucky law requiring transfer agreements fails to offer benefits that outweigh the burdens it imposes, and thus is unconstitutional by the standard set forth in Hellerstedt.
In rural areas, TRAP laws aren’t the only threat to abortion clinics. Some clinics may close because there simply aren’t enough doctors to staff them, Donovan said. “Abortion, of course, is highly stigmatized and it’s difficult to find providers who are willing to practice, particularly in hostile and sometimes dangerous environments,” she explained. “So you can imagine being isolated in a rural community and being that much more of a target.”
Maternity care in rural areas also faces a number of different threats. “Rural health care in general is particularly vulnerable to reductions in state and federal budgets and workforce supply,” the study authors note — and when hospitals have to cut costs, obstetric care is often the first to go. In places with few births per year, it may not be cost-effective for hospitals to offer maternity care.
Patients giving birth in rural areas are disproportionately likely to be covered by Medicaid, putting rural hospitals in a difficult financial position. Medicaid reimburses for maternity care at about half the rate of private insurance, said Kozhimannil. Any cuts to Medicaid, like those proposed in recent Republican plans to repeal the Affordable Care Act, would have a disproportionate impact on maternity care in rural areas.
It can also be hard for rural areas to recruit and retain obstetricians, said Kozhimannil, since doctors working in underserved areas have to travel long distances and work long hours to take care of patients who have no one else to go to. The more facilities stop offering maternity care, the worse this problem gets.
Abortion and maternity care are closely linked — even if laws try to separate them
“There has long been an assumption that one could separate out issues around abortion from issues around birth,” said Lynn Paltrow, the executive director of National Advocates for Pregnant Women. But, she noted, the majority of women who get abortions already have children. “Any given woman in her lifetime is very likely to need both birth support and abortion,” she explained, and both are becoming less and less available.
That’s especially true in rural areas. “Rural people in general have less and less access to the heath care they need,” Paltrow said.
The Improving Access to Maternity Care Act, which passed in the House of Representatives in January but has yet to get a vote in the Senate, would help address problems with doctor recruitment and retention in rural communities, said Kozhimannil. The bill would allow the federal government to identify areas with shortages of maternity care doctors and place obstetricians and certified nurse midwives in those areas, according to Elissa Strauss at Slate.
In places that have lost maternity care, hospitals, emergency medical services, law enforcement, and others need to plan for the emergency births that will happen when mothers can’t get to a hospital in time, Kozhimannil said. And rural areas can follow the example of programs in Alaska to offer transportation and housing help to women who have to travel to give birth.
Access to contraception and family planning services are especially important in rural areas where both abortion and maternity care providers are far away, Kozhimannil added.
For her, a measure of empathy among policymakers is also crucial. “Most of the people that conduct this research and make these decisions are people that have spent all of their adult lives in urban areas,” she said. “It’s really important for people who make these decisions and policy to think about what it’s like for rural women and families.”
The natural disaster makes the impact of state’s many abortion restrictions even worse.
The full scale of Hurricane Harvey‘s devastation will become clear in the coming weeks as Texans return from shelters and hotels to clean up their homes, or what’s left of them. Adding to the stress of rebuilding after a disaster was the temporary closure of abortion clinics in Houston. The state already has multiple barriers to access abortion, including state-directed counseling with a misinformation-riddled pamphlet, 24-hour waiting periods before the procedure, and mandatory ultrasounds.
Abortion provider Whole Woman’s Health announced on Friday that it would cover the cost of abortions during the month of September for women affected by Hurricane Harvey as they may have missed their appointments or may have a harder time affording care. Whole Woman’s Health will provide “financial and logistical” assistance to make sure women can get to one of its four Texas clinics—in Austin, San Antonio, McAllen, and Fort Worth—and will cover travel and lodging costs, if necessary.
In a post on its blog, they wrote: “Continued political attacks on abortion access make an unwanted pregnancy particularly stressful in Texas—add that to the stress of dealing with hurricane aftermath. We can only imagine what a stressful time this must be for those patients who had to miss their appointments or are waiting for the nearest clinic to open.”
The provider will use its own Stigma Relief Fund and money from the Texas-based Lilith Fund to cover the cost of care. The Lilith Fund has even created a specific emergency fund for Harvey survivors who need abortion care. People who live in areas hit by the hurricane and need abortion care can call Whole Woman’s Health at 877.835.1090.
Texas is not exactly a friendly place for women’s reproductive rights. This is a state where women are now required to take out “rape insurance” for abortion, after Governor Greg Abbott signed a law banning all insurance coverage of the procedure, even, unbelievably, in the cases of rape, incest, and fatal fetal abnormalities.
Whole Woman’s Health is the provider that sued the state over its unconstitutional clinic shutdown laws, like HB2. They won a Supreme Court case last June which found that requiring doctors to have admitting privileges at nearby hospitals and mandating that abortion clinics meet the standards of ambulatory surgical centers amounted to an undue burden on women’s ability to access abortion care. Still, more than half of the state’s clinics had shuttered since HB2 was signed in 2013 and it takes time to re-open, which can lead to longer wait timesand higher costs. It’s a vicious circle perpetuated by conservative lawmakers that disproportionately impacts low-income women and women of color.
Abbott also signed a law that would ban an abortion procedure known as dilation and evacuation (D&E), which the American College of Obstetricians and Gynecologists says is the most common way to terminate a pregnancy after 13 weeks. Whole Woman’s Health, Planned Parenthood, and other reproductive health providers are suing the stateand the ban has been temporarily blocked.
Whole Woman’s Health wrote on its blog on Friday: “The need for abortion care does not stop for natural disasters.”
“I teach all of my residents, I teach all of the medical students, this is not the standard of care.”
Nationwide, Catholic directives govern one in six acute-care hospital beds; Wisconsin is one of five states where that rate is more than 40 percent.
Marc Faletti / Rewire
Religious imposition laws are designed to shield private individuals and businesses from complying with nondiscrimination laws based on a religious objection to that service.
Dr. Jessika Ralph was waiting for her patient to get sick.
The young woman had arrived at Wheaton Franciscan-St. Joseph hospital in Milwaukee, Wisconsin, in labor. She was 18 weeks pregnant, and her twin fetuses were long from viable. She miscarried one fetus within hours of admission, but her labor stalled while the second still had a heartbeat. Because the hospital followed rules issued by the Catholic Church, until the patient hemorrhaged or showed at least two signs of infection—fever of 100.4 or higher, uterine tenderness, rapid heart rate, or rapid fetal heart rate—Ralph could do little except watch her sicken.
So Ralph’s team trimmed the umbilical cord from the miscarried twin as short as possible to minimize the infection risk, and waited overnight.
After about 10 hours, the patient’s temperature soared to 102 or 103 degrees, Ralph recalled in an interview with Rewire in June, a few months after the incident. Ralph and her team gave the patient medication to induce labor. But Ralph could not administer mifepristone, which the American College of Obstetricians and Gynecologists (ACOG) considers part of the most effective drug regimen for such cases. The Catholic hospital didn’t carry the drug, which is commonly used for medication abortions—a failure Ralph believes was religiously motivated and needlessly prolonged her patient’s labor.
At first, the patient’s goals seemed to align with the hospital’s rules, Ralph said: She wanted to try to continue her pregnancy to a viable gestation, even though the chances were slim. But as she rapidly sickened, she and her family pleaded with Ralph to speed up the process of ending her pregnancy. Ralph felt powerless. The fastest, safest method for terminating a second-trimester pregnancy—a surgical procedure called dilation and evacuation (D and E)—was not offered at St. Joseph, where no supervising physicians were capable of performing the common abortion procedure, Ralph said.
For more than 24 hours, the patient labored through painful contractions. She bled heavily, requiring at least one blood transfusion. Her lips and face lost their color. Finally, she delivered a fetus that had no hope of survival.
If the patient had gone to Froedtert Hospital, about five miles away, she would likely have been offered the option of a surgical abortion or induction, without having to get sick first. If she had chosen induction, she could have received mifepristone.
The patient survived her ordeal. Due to medical privacy laws, Rewire could not contact her, but we confirmed Ralph’s account of the hospital’s policies with fellow residents and experts who said such constraints are typical for the growing number of hospitals nationwide that follow directives written by the U.S. Conference of Catholic Bishops. These rules restrict access to contraception, sterilization, abortion, and end-of-life care, although how they apply can vary based on the hospital, doctor, and even the local Catholic bishop who oversees compliance with the directives. Providers have cited these rules to deny transition-related surgery to transgender patients, emergency contraception to rape victims, and abortion care to patients in the potentially life-threatening process of losing their pregnancies, like the woman Ralph treated.
A combination of factors are now giving Catholic hospitals unprecedented power over U.S. health care. Recent decisions by the U.S. Supreme Court and President Donald Trump are poised to hand Catholic hospitals almost unfettered leeway to impose religious doctrine on patients and their own employees. And the reach of these hospitals is expanding. Nationwide, the directives govern one in six acute-care hospital beds; Wisconsin is one of five states where that rate is more than 40 percent.
To get a sense of how profoundly the Catholic directives shape access to reproductive health care, Rewireinterviewed doctors who rotated through three Milwaukee hospitals as part of a four-year OB-GYN residency at the Medical College of Wisconsin (MCW). Two of the hospitals, St. Joseph and Columbia St. Mary’s, are run by Ascension Health, the largest Catholic health system in the world and largest nonprofit health system in the United States. Ascension declined to respond to a detailed list of questions for this article, including the concern that its hospitals’ policies put patients at risk.
The third hospital where the residents worked, Froedtert, is not Catholic.
Dr. Jessika Ralph (Amy Littlefield/Rewire)
This situation put doctors like Ralph, who completed her residency in June, on the front lines of one of the most contentious areas of U.S. health care—the role of religion in medicine. Ralph and her colleagues saw firsthand how, even within the same city, a patient’s care could vary dramatically depending on whether she happened to wind up in a Catholic hospital or not. And in one of the country’s most segregated cities, the residents said, the impact of these religious restrictions often fell most heavily on low-income patients of color. St. Joseph, which is located in a mostly Black neighborhood, and the other Catholic hospital, St. Mary’s, both see a significantly higher share of Medicaid patients than Froedtert, according to data from Definitive Healthcare.
Ralph and the other residents interviewed by Rewire found ways to serve patients as best they could, while staying within religious rules that sometimes forced them to go against accepted medical standards. For Ralph, who trained medical students and fellow residents, an important part of that work was speaking out against the Catholic directives. She admonished her trainees to provide mifepristone when inducing labor at any hospital that allowed it, for example.
“I teach all of my residents, I teach all of the medical students, this is not the standard of care,” Ralph told Rewire, slamming her hand on the table to punctuate her words. “I tell them, at Froedtert, you better be giving them mifepristone. I will be very disappointed in you if you do not, and anywhere that you go, you better be giving them mifepristone, because we know that it makes this process safer.”
“I Was So Worried That She Would Never Trust a Doctor Again”
In less than 1 percent of pregnancies, a patient’s water breaks before the fetus is viable. When this happens, ACOG recommends patients be counseled about the risks of trying to continue the pregnancy versus ending it immediately.
“Immediate delivery should be offered,” the ACOG bulletin states.
That’s what happens at Froedtert Hospital, where patients are counseled about the risks and benefits of all options, including remaining pregnant, according to Dr. Kate Dielentheis, an OB-GYN who works there.
“My strong medical recommendation is that in a previable, preterm rupture of membranes, or premature rupture of membranes, it is not safe to stay pregnant, because of the infection risk and the risk that mom can get very, very, very sick,” Dielentheis, an assistant professor at MCW, told Rewire in a phone interview.
But patients at Catholic hospitals often have no choice but to run that risk if the fetus has a heartbeat.
In rare instances, the consequences of maintaining a pregnancy under these circumstances can be fatal, as in the case of Savita Halappanavar, who died of septicemia in 2012. Halappanavar had sought care while in the process of losing her pregnancy at a hospital in Ireland, where abortion is illegal in most cases. The hospital denied her an abortion; one practitioner told her Ireland was a “Catholic country.”
In the United States in 2010, a Catholic hospital in Michigan sent Tamesha Means home twice after her water broke at 18 weeks. When she returned a third time with an infection, the hospital prepared to send her home again, treating her only after she began to deliver, according to the American Civil Liberties Union, which sued the hospital and the U.S. Conference of Catholic Bishops on her behalf. Means survived.
Residents like Ralph may face less extreme versions of this scenario a few times a year.
“You’re in this limbo of knowing that the right thing to do is to induce her labor because she is going to get sick. And when we say sick, I mean, it’s not common but they can die, they can become septic and die from something that we could treat and prevent and never have them get ill,” Ralph said. “How do you tell this patient, in good conscience, ‘I’m waiting for you to get sick?’”
The Catholic directives forbid abortion, but allow procedures aimed at alleviating a serious risk to the pregnant person, even if they also happen to end the pregnancy.
But how this rule applies in practice—how sick a patient must get before she can be treated, and what that treatment entails—can vary, even within the same hospital.
In a case from a few years ago that still troubles her, Ralph was ordered to send a young patient home from St. Joseph after her water broke at 18 or 19 weeks. Typically, doctors would keep patients like her under observation for 24 hours, but the attending physician overseeing Ralph was concerned about the financial cost of keeping her, particularly since little could be done to help the patient due to the directives. So the attending told Ralph to discharge her after several hours.
The patient, still reeling from the news that she was likely to lose her pregnancy, was furious and frightened. She couldn’t understand why the hospital was sending her home if she was at risk of infection, Ralph recalled.
“I had to be the one to go in and say, ‘I have to send you home,’ even though it’s not what I wanted to do … and explain to her, essentially, come back when you’re really sick, and then we can take care of you,” Ralph said. “I was so worried that she would never trust a doctor again.”
Before sending her home, Ralph told the patient she would have more treatment options at Froedtert Hospital. She was careful not to document that advice in the patient’s medical record, for fear of ruffling feathers at St. Joseph. The patient checked into Froedtert the next day, Ralph learned.
Sometimes, the residents would help patients get care at Froedtert if they were in the process of losing their pregnancies and wanted a D and E or a prompt induction. If a patient was under the care of certain attending physicians who opposed abortion, residents knew such referrals were off limits.
Even at Froedtert, terminating a pregnancy was not always seamless. Some doctors and staff who opposed abortion refused to take part in D and Es, which could stall surgeries. Froedtert does not perform abortions unless two doctors attest that there is a lethal fetal anomaly or significant risk to the patient. Unlike the Catholic hospitals, however, Froedtert deems it a sufficient risk if a patient’s water breaks before viability, even without an infection.
Spokespeople for Froedtert and MCW declined to comment for this story. Dielentheis, the OB-GYN who works there, confirmed the hospital’s policies on abortion and said that in her experience, enough doctors there are willing to perform D and Es that moral objections by other physicians do not delay care.
At the Catholic hospitals, residents felt they were forced to place an implicit moral condemnation on patients.
“Even if you’re not personally putting a judgment on them, that kind of comes with an inherent judgment. You know, like, I’m not saying what you’re doing is wrong, but I can’t do it here, because it violates the Bible,” Dr. Sarah Krueger, who finished her MCW residency alongside Ralph, told Rewire. “Even if you don’t feel that same way, your patients kind of feel like you’re judging them.”
“It Feels Like I’m Letting Them Down”
Dr. Molly Isola, who is due to finish her MCW residency next year, grew frustrated with a note she saw repeatedly in her patients’ medical records.
“I’ve seen more than one patient who, in her notes, it will say, ‘wanted a tubal ligation last time but couldn’t get it where she delivered,’ and now she’s pregnant again,” Isola told Rewire in a phone interview.
These were patients who delivered babies via cesarean section and wanted to have their “tubes tied” at the same time, a common practice that obviates the risk and cost of a second surgery. But under the Catholic directives, Columbia St. Mary’s hospital forbids tubal ligations under any circumstances.
“I just don’t feel that it’s ethical to require someone to have a second surgery that isn’t necessary,” Isola said. “It could all be done at once.”
Isola would offer to refer her patients to another hospital that allowed tubal ligations, but some chose to deliver at St. Mary’s anyway, either because they had done so before, or because, like many patients at the hospital, they spoke Spanish, and wanted a midwife from the bilingual clinic that partners with St. Mary’s.
At St. Joseph, tubal ligations were allowed only during a c-section, following approval by an ethics committee that considered factors like prior c-sections and medical conditions that could make pregnancy dangerous. Krueger, for example, applied for a tubal ligation for a patient who was pregnant with twins and had more than five children, but because all of the patient’s previous deliveries were vaginal and she was relatively healthy, the request was denied. Some fear the policy could become even stricter after Ascension, which already owned St. Mary’s, acquired St. Joseph, and other Wheaton Franciscan hospitals in the area, last year.
Krueger also found herself frustrated with the contraceptive policies at St. Joseph, where the residents’ clinic didn’t stock long-acting reversible contraceptives like intra-uterine devices (IUDs). In yet another sign of the inconsistency of such restrictions, the residents’ clinic at St. Mary’s did stock some of these methods.
In segregated Milwaukee, St. Joseph sits in a low-income, predominantly Black area. It wasn’t uncommon for Krueger’s patients to take three buses or walk dozens of blocks to reach St. Joseph for medical care. Often, their pregnancies were complicated by consequences of poverty and racism—poor access to nutritional foods, which can fuel health conditions like diabetes; exploitative jobs that didn’t afford time off for medical appointments; or unstable housing.
For these patients, adding an additional barrier, like sending them elsewhere for another medical appointment, often meant they just never got the care they wanted.
One patient became pregnant again only to lose her fetus in the second trimester, an ordeal that Krueger believes could have been avoided if the patient had been able to get an IUD at her postpartum visit.
“It feels like I’m letting them down,” Krueger told Rewire. “These patients have had negative interactions with health-care providers before and so they come in jaded and guarded and not trusting and you build this really awesome, awesome relationship with them, but then at the end, that’s something that they really need … it impacts their life forever. And I can’t give that to them.”
While Krueger and her colleagues received relatively comprehensive reproductive health-care training at Froedtert, some residents aren’t so lucky. About 13 percent of OB-GYN residency programs in the United States are at faith-based institutions with restrictive policies on family planning, according to Maryam Guiahi, an assistant professor at the University of Colorado School of Medicine.
Graduates of these programs often report being unable to provide basic services like IUD insertions and tubal ligations, instead relying on colleagues or even watching YouTube videos to compensate for their lack of training, Guaihi wrote in a recent article for the Journal of Graduate Medical Education.
Ultimately, that means patients can suffer from delays and inadequate counseling, even in secular facilities, if their doctor was trained in a Catholic institution.
As for the residents Rewire interviewed, an important lesson they learned was to avoid institutions with religious restrictions on health care. Both Ralph and Krueger have accepted positions where they can provide care without these barriers, and Isola said she asks potential employers about them.
“I haven’t just ruled out [working for] Catholic hospitals as a rule, but the things that I want don’t seem compatible with most if not all” of these hospitals, Isola said.
Ten leaders of anti-abortion groups are urging Congress to defund Planned Parenthood using a fast-track budget maneuver that is immune to filibuster.
The leaders, led by the Susan B. Anthony List’s Marjorie Dannenfelser, asked Republicans in a letter Tuesday to revisit the fiscal year 2017 reconciliation bill “immediately” to defund Planned Parenthood.
That bill was supposed to be used to repeal parts of ObamaCare, but Senate Republicans could not find the support within their party to pass it, and given a raft of congressional must-do items, that effort seems unlikely.
“The pro-life majority that now controls both chambers of Congress and the White House mustpass a reconciliation bill stopping the vast majority of federal funding for Planned Parenthood,” the leaders wrote in the letter.
“Doing anything less brings into question whether this Congress can truly be called the Pro-life Congress. Rhetoric must be translated into law.”
The leaders urged Republicans to “immediately” find consensus on a bill that “takes Planned Parenthood off the federal Medicaid dole and offers women comprehensive alternatives.”
“Whether that is a broad pro-life healthcare reform package or a narrower bill is up to Congress to determine, but giving up is not why the voters sent pro-life Republicans to Congress,” the leaders wrote.They said Congress should defund Planned Parenthood using the fiscal 2018 bill should time for the 2017 bill run out.
The 2017 reconciliation bill expires at the end of the month.
Current law already prohibits federal funds from being used for abortions, but opponents of Planned Parenthood argue that money still indirectly supports abortion.
The Senate GOP’s health care bill would have defunded Planned Parenthood by blocking Medicaid reimbursements for one year.
It also would have banned the use of ObamaCare subsidies for plans that cover abortion.
The letter was signed by Dannenfelser, as well as Family Research Council president Tony Perkins and Americans United for Life president and CEO Catherine Glenn Foster, among others.
A Houston Police dive team boat rescues individuals during the aftermath of Hurricane Harvey on August 27, 2017 in Houston, Texas.
Brendan Smialowski/AFP/Getty Images
Whole Woman’s Health, a group of clinics that provide abortion care and other health services, announced on Friday that it will offer free abortions to women impacted by the devastation of Hurricane Harvey. Noting that women in the Houston area and elsewhere in southeast Texas may have had to miss abortion appointments during the storm, a blog post on the Whole Woman’s Health website promised to help affected women get to one of the organization’s four Texas locations for abortion care at no cost.
“During Hurricane Harvey, many of the clinics in Houston had to close temporarily, leaving women with very few options,” the post read. “Continued political attacks on abortion access make an unwanted pregnancy particularly stressful in Texas—add that to the stress of dealing with hurricane aftermath.”
Natural disasters exacerbate existing logistical and financial barriers to women’s health care access. Women on Medicaid can’t use their insurance to cover or subsidize abortion care, and low-income women may save for weeks to afford the procedure, only to find that they’re too far along to get a cheaper medical abortion or to get a legal abortion at all in the state. After losing property or wages to a hurricane, even more women may find it difficult to pay for an abortion. Where it was once merely difficult to afford child care and time off work to accommodate an abortion appointment, after a natural disaster, it can be nearly impossible. And since women are usually the default caretakers of their families, they face the bulk of the extra responsibilities that come after a tragedy, including making arrangements for relief, organizing relocation, and caring for the young and old. This further diminishes the reserves of time and resources available for their own health care.
For the month of September, Whole Woman’s Health—the successful plaintiff in last summer’s landmark Supreme Court case on abortion restrictions—will cover both travel and housing costs for Harvey-affected women who need help getting to the organization’s outposts in Austin, Fort Worth, McAllen, or San Antonio. The group will draw from its own abortion fund, the Stigma Relief Fund, as well as the Lilith Fund, a Texas-specific abortion-funding organization that has established an emergency fund for care for Harvey survivors. Slaterecommended donating to abortion funds after Donald Trump’s election because they support people who, by virtue of their class, geographic location, or immigration status, can’t access abortion care, a right wealthier women will almost always be able to enjoy. It’s for this same reason—that they empower the most marginalized people exercise autonomy over their own bodies—that abortion funds are essential resources in the aftermath of a natural disaster.
All over the world, in all kinds of crisis situations, women’s sexual and reproductive health care is one of the first basic needs to fall through the cracks of disaster relief. Rates of sexual assault rise in crisis zones, and distraught survivors are more likely to engage in sexual behaviors that put them at risk for unwanted pregnancies and sexually transmitted infections. At the same time, agencies focused on food, shelter, and first aid often neglect sexual health needs that don’t go away when disaster strikes. The American Congress of Obstetricians and Gynecologists recommends that emergency health care providers stock up on emergency contraception, preventive contraception, and condoms when they help communities recover from a natural disaster. These are resources no one’s sending in their donation boxes of diapers and canned food.
Abortion care is even trickier to ensure in the wake of a crisis, since federal funds can’t be spent on abortions and politicians may be reluctant to single out a controversial medical procedure as a critical need during a time of recovery. Abortion funds in Texas are filling in the gaps of Harvey relief, because that’s what abortion funds are designed to do.
An abortion can be an emotional experience that raises questions about a woman’s relationships, past regrets, and future. She might want to confide in someone about these feelings in the following weeks, months, or years.
Abortion opponents have taken that complex reality to a disturbing extreme, with the hope of convincing the public and lawmakers that ending a pregnancy puts many women at significant risk for mental health problems like substance abuse, depression, and suicide.
To vividly and persuasively make their case, anti-abortion rights activists often point to scientific research that makes dubious connections between the medical procedure and long-term psychological turmoil or suffering. What politicians looking to restrict abortion don’t tell the public is that not all research in this field is equal.
“No one needs to tell us that we need to take time to think. People are doing it anyway.”This strategy has found its way into statehouses across the country. A recent report from the Guttmacher Institute, a research and advocacy organization, found that more than half of all women of reproductive age in the U.S. live in a state with at least two types of abortion restrictions that have no basis in scientific evidence, including counseling requirements and mandatory waiting periods.
Not all of these laws are explicitly premised on the notion that abortion causes lasting emotional or psychological damage, but many are routinely defended as measures to protect women’s health.
“I don’t think requirements are the solution to anything,” said Melissa Madera, who has interviewed 288 people about their abortion experiences as founder and director of the podcast The Abortion Diary. “No one needs to tell us that we need to take time to think. People are doing it anyway.”
Meanwhile, a battle over the science of abortion and mental health continues to unfold: Reputable medical and professional organizations in the field have found that the procedure doesn’t cause long-term psychological harm, but a group of researchers insist it’s devastating.
The losers in this fight? People who’ve had or may need an abortion and hear conflicting messages about the research, and who may face long waits to get care because of laws designed to slow the process.
While many women who’ve had abortions can share how the experience affected them, scientists can’t rely on these anecdotes to draw conclusions about mental health for an entire population. Instead, the best scientific research minimizes bias and controls for variables. When randomized trials are possible, scientists can recruit volunteers who are then assigned different outcomes.
With abortion, however, that would mean randomly selecting whether a woman carries an unintended pregnancy to term or ends it — disturbing, unethical, and impossible. Instead, research on abortion and mental health outcomes must rely on what are known as observational studies. That means women choose whether to end or complete their pregnancy, and then scientists follow those two groups over time to observe and compare their mental health outcomes. Scientists can make inferences about what they find in observational studies, but it’s more challenging to draw a straight line between cause and effect.
The path from pregnancy to developing a specific mental health experience can be nearly impossible to accurately track. Efforts to untangle the relationship between pregnancy and a specific mental health experience, particularly when abortion is involved, often fall short, said Julia Littell, a professor of social work at Bryn Mawr College who specializes in research design and synthesis but does not publish on abortion.
Research shows, for example, that the experiences that make women more likely to have an unintended pregnancy or abortion — like poverty, childhood sexual and physical abuse, and domestic violence — also are associated with an increased risk of developing a mental health condition. If they experience depression or anxiety and have had an abortion, it’s crucial for researchers to know which came first.
In the past decade, two major U.S. and UK professional organizations, the American Psychological Association and the Academy of Medical Royal Colleges, conducted in-depth reviews and found that the best evidence indicated ending an unplanned pregnancy in the first trimester posed no greater risk for mental health problems than giving birth.
That comparison helps to lay bare a political agenda that’s often more obsessed with protecting women from the potential effects of abortion than supporting women with the various emotional and psychological challenges of motherhood. Politicians, for instance, aren’t clamoring to pass laws making it harder for women to get pregnant because they might experience postpartum depression, anxiety, or psychosis.
More than 20 years ago, Mika Gissler, an epidemiologist and research professor of public health at The National Institute for Health and Welfare in Finland, published a study that anti-abortion activists have cited as proof that abortion can lead to suicide.
He analyzed the mortality risk of more than 600,000 women in a national register who gave birth or had an abortion. In his 1996 BMJ study, those who ended a pregnancy were at a much higher risk of dying by suicide, and he found the same to be true again in a studypublished in the European Journal of Public Health, in May.
But Gissler, after studying this cohort for two decades, believes there’s a more complex explanation for the association between abortion and suicide. First, his studies can’t account for pre-existing mental health conditions because the register lacksdetailed information about their experiences. Gissler also thinks that motherhood itself largely reduces risky behavior like self-harm. The Finnish healthcare system plays a critical role as well by giving teenage mothers, the subject of his latest study, intense support during and after pregnancy. Teens who have an abortion don’t get the same reinforcements.
Though his 1996 study noted the possibility that abortion might negatively affect women, he holds no reservations now. “[I]t’s quite clear it’s not the abortions,” he said. “It’s the complex situation of the women.” Abortion and suicide, he noted, share the same risk factors, including economic instability and limited education.
Gissler said he’s been courted by anti-abortion researchers, some of whom he characterizes as well-versed in statistics but lacking expertise in mental or reproductive health epidemiology.
“They are making wrong conclusions and really bad science, if you can even call it science,” he said.
Though it might surprise some to learn that peer-reviewed journals publish questionable research, Littell said it does happen. A journal editor, for example, may not fully understand a study’s methodology and findings.
In 2008, a group of researchers published a review in Contraception suggesting that quality made a huge difference in abortion research. The highest quality studies did things like control for pre-existing mental health conditions and other important confounders, use the most appropriate comparison groups, and use widely accepted mental health measures. The review concluded that the highest quality studies don’t indicate abortion leads to long-term mental health problems, whereas the low quality studies largely reported a relationship between the two experiences. The authors also acknowledged that a “minority” of women experience “lingering post-abortion feelings of sadness, guilt, regret, and depression.”
“The goal of any such research should be to uncover the truth and share that with women and patients.”“The goal of any such research should be to uncover the truth and share that with women and patients,” said Chelsea B. Polis, co-author of the Contraception study and a senior research scientist at the Guttmacher Institute.
If that seems self-evident, consider that the debate over abortion and mental health is a lot like the controversy that has plagued research on climate change, evolution, or vaccines: A vocal group of researchers sees the scientific consensus as the product of bias, ethical misconduct, or even conspiracy and sows doubt at every possible turn. This isn’t just professional disagreement — it quickly begins to look like an ideological struggle.
Take, for example, what happened in December when JAMA Psychiatry published the largest and longest prospective study in the U.S. comparing the mental health outcomes of women who had an abortion to those of women denied an abortion. It followed 956 women over the course of five years, compared four groups with different abortion outcomes, and found that ending a pregnancy did not appear to increase a woman’s risk of developing mental health symptoms.
Those who had an abortion did not experience higher rates of anxiety, depression, low self-esteem, or low life satisfaction than those who were denied the procedure. In fact, women turned away from a clinic because they exceeded the facility’s gestational limit initially had higher levels of anxiety, lower self-esteem and less life satisfaction than those who had the procedure. Between six and 12 months, however, all of the women had similar mental health outcomes throughout the remainder of the study.
“I think that if the claim is to protect women’s mental health, what researchers are finding is that allowing women to make decisions and access care is more protective than denying them care,” M. Antonia Biggs, the study’s lead author, said.
The study garnered praise as providing “the best scientific evidence” on the mental health effects of abortion from a former director of reproductive health at the Centers for Disease Control and Prevention.
However, Priscilla K. Coleman, a professor of human development and family studies at Bowling Green State University whose own body of work consistently demonstrates a relationship between abortion and increased risk for mental health problems, criticized the study as methodologically flawed in a self-published rebuttal, and suggested there was a broader conspiracy to publish fraudulent results that bolstered the case for abortion rights.
“If we really wanted to promote [an agenda], we would have wanted to find more negative outcomes for the women denied abortion,” said Biggs, who is a social psychologist researcher with Advancing New Standards in Reproductive Health, a research group at the University of California at San Francisco.
Coleman said that she supports waiting periods and “sensitive, individualized pre-abortion counseling” and will oppose abortion until well-designed studies demonstrate it is beneficial to women. Coleman has served as a paid expert witness in abortion-related legal cases and for legislatures that considered restrictive measures, but her research has also been thoroughly critiqued.
“I know it’s appropriate science. I know I care about women. I just know what I’m doing is right.” A 2009 study Coleman published in the Journal of Psychiatric Research, which did not account for whether women had pre-existing psychological conditions, became the subject of heated criticism, and elicited a critical note from one of the journal’s editors. In 2012, the Eighth Circuit Court of Appeals cited her testimony when it upheld a South Dakota law that required physicians to tell patients they may be at greater risk of suicide if they have an abortion. The decision also cited Gissler’s 1996 paper. The dissent noted, however fruitlessly, that Gissler disavowed a causal link between abortion and suicide.
“We have to promote sexual and reproductive health and mental health, and have a checkup after the abortion to avoid any suicide [risk] instead of restricting women’s possibility to terminate pregnancy when they need it,” Gissler recently said.
In 2011, Coleman published a controversial study in the British Journal of Psychiatry. It attracted some support, but also prompted several letters of concern from researchers across disciplines who said the meta-analysis was poorly designed and didn’t account for the quality of the evidence it cited. Littell argued that it violated basic rules for synthesizing scientific research and called for its retraction. The editor declined to do so, a point Coleman raises in defense of her work.
Coleman said that she doesn’t routinely include published criticism of her work in expert testimony, but does address them in rebuttals when necessary. “I know it’s appropriate science,” she said of her research. “I know I care about women. I just know what I’m doing is right.”
Whether women might need emotional or psychological support after an abortion is an important public health question. The National Abortion Federation advises clinics to provide patients with counseling referrals and resources, and all medical providers must abide by informed consent laws and present patients with information about the procedure, its risks, and alternatives.
“You can make the choice to have an abortion and still feel complicated feelings about it.”Lawmakers opposed to abortion, however, just don’t believe any of those measures go far enough.
Madera believes that counseling should be easily accessible for abortion patients. Her intimate knowledge of other people’s abortion experiences, along with her own at the age of 17, has made her skeptical of competing social or political narratives that abortion is always traumatic or always simple.
“You can make the choice to have an abortion and still feel complicated feelings about it,” she said.
Instead of acknowledging that reality, though, politicians are using it to justify restricting a woman’s right to choose in the first place.
From Syria to Nigeria and Colombia, women rescued from the horror of war face losing the services that in many cases have saved their lives
A South Sudanese refugee who was raped for several days by soldiers stands by a window at a women’s centre run by the International Rescue Committee, in Bidi Bidi, Uganda. Photograph: Ben Curtis/AP
Tara Sutton in Amman, Joe Parkin Daniels in Fundación, and Ruth Maclean in Maiduguri
Tuesday 1 August 2017 07.00 BSTLast modified on Wednesday 2 August 2017 11.09 BST
If the first victim of war is the truth, the second is often female. And the people who pick up the pieces are usually aid workers, as it is their health centres and “safe spaces” and camp programmes that help women to work through the trauma of loss, displacement and sexual violence.
But all that is now at risk, after President Donald Trump’s decision to reinstate the so-called Global Gag rule, which will ban funding to any non-US aid groups that offer abortion services or advice funded from other partners.
As the cases below demonstrate, often the support given to these victims of war will have nothing to do with abortion. But, because the provider might be linked to abortion advice elsewhere in the world, the life-saving programmes they offer are in jeopardy. Without US funding, some are likely to close by the end of the year.
And through no fault of their own, women suffering the agonies of war will find themselves alone.
Menash’s story
Menash had been a sex slave for Islamic militants Boko Haram for months when one of her kidnappers declared he wanted to marry her.
She refused – she was already married with six children – although her husband had fled their home when she and her sister were abducted. Eventually, she escaped.
As she sits in a quiet cubicle in Muna camp in Maiduguri with her baby son, the trauma Menash experienced shows in her movements and on her face: her head, her eyes, her strong hands, all seem heavy under the weight of what she went through in the Sambisa forest.
Menash holds her baby at the ‘safe space’. Her neck is scarred from when a Boko Haram militant tried to behead her. Photograph: Ruth Maclean for the Guardian
“Five men used to come and rape me,” she said. “I complained about them to the man who wanted to marry me, but he just said: ‘That’s their tradition. That’s what they do.’ Even if I’d married that man, the others would have kept raping me.”
We are sitting in a safe space created by the UNFPA to help women like Menash, of whom there are thousands in this camp alone.
This is a place that welcomes women who have fled their homes or, like Menash and like the Chibok girls, escaped captivity under Boko Haram, which abducted, raped and murdered thousands of Nigerians, and left millions homeless.
Far from home, with no money or food and still facing violence and sexual assault in the camps, women can come to these hastily thrown-up buildings, sit on colourful plastic mats spread on the concrete floor, talk to each other, watch television, and learn to sew or make detergent to sell.
But as the US defunding of UNFPA threatens projects like this, the question is: for how much longer?
Here, the fund not only helps women get contraceptives, if they want them, but does much more. In camps across Nigeria’s north-east, they hand out soap, sanitary towels and clothes to those who have just escaped from Boko Haram and who often arrive in rags with nothing. Midwives examine pregnant women, sending those with complications for further medical help. Women who need counselling, like Menash, also get help.
Menash had not anticipated what her punishment would be for refusing to marry her captor, but she thought it could not be much worse than what she was already living through. However, then she was taken outside and made to kneel in the dirt, surrounded by other women including her sister.
As the sewing machines whirr outside our cubicle, she lifts her hijab over her face and leans forward, her fingers tracing a scar on the back of her neck. “They tied me up and tried to cut my head off,” she said. “I thought my life was over.”
Women at the ‘safe space’ at the Muna camp in Maidguri learn how to make soap to sell. Photograph: Ruth Maclean for the Guardian
She had been struck several times by a knife when a plane overhead suddenly made her attacker flee, along with other insurgents. But Menash’s hands were still tied behind her, with blood pouring down her back. Suddenly, her sister ran to her and helped her up.
“She cut the rope around my hands, and I ran, I just kept running. I couldn’t stop,” said Menash. “But my sister was not running fast enough. I haven’t seen her since.”
In Maiduguri, her husband rejected her, she said. He shouted at her to “get away”, calling her a “Boko Haram whore” and beating her.
“Nobody took my side, they were all yelling ‘Boko Haram wife’ at me,” she said quietly. “I just turned around and left.”
When she met Zainab Umar, a counsellor at Muna’s safe space, several months later, Menash was starving and dirty, and her hands shook violently. She said strangers sometimes laughed about her to her face and spread her story around.
Around 60% of women are estimated to have experiencedgender-based violence in the north-east of Nigeria and rape is rife in the camps. The need is huge for Umar and her colleagues, who work non-stop to counsel women like Menash and help them to get on their feet financially. Nevertheless, health workers and counsellors in the 20 safe spaces for women and girls across the region are not sure how much longer they will have jobs.
The UNFPA – which suffered another blow last month, when its director Babatunde Osotimehin died suddenly – is trying to find other donors to fill the gap left by the US. But it is a difficult time to raise money in Nigeria, where less than a third of the $1bn needed to address the humanitarian crisis created by the rise of Boko Haram has been raised.
Menash approached Umar and asked for something to eat after she had seen her talking to women in the camp. Umar explained that she wasn’t offering food, but family planning advice, neonatal checks and counselling. “Initially, I thought I wouldn’t bother,” said Menash. “But then I thought – even if he can’t give me anything, maybe I should see her. No one had been kind to me.”
Even after she had decided to go, it took her a while to open up. But then Umar told her that Boko Haram had made her suffer, too. “She told me: ‘They killed my own son ,’ so then I thought, I can share my story with this woman.”
Umar’s approach to the dozens of women she sees each day is simple. She reassures them that their conversation is confidential and encourages them to talk about their experience, and then tries to find ways for them to keep busy as a distraction.
“Many of their husbands have been killed, and many are traumatised,” said Umar.
Aseel’s story
Aseel, 25, had done the hard bit. She had escaped from Isis and its stronghold in Raqqa, her hometown, and she had made it to the relative safety of Jordan.
But that’s where her problems deepened. Penury stalked Aseel, who lived with her husband in a makeshift shack on a roof. The birth of her first child merely deepened her sense of loss, alienation and depression.
She stood on a roof edge and prepared to jump, but a neighbour intervened and took her to the Noor Al-Hussein Clinic in Amman, Jordan, a one-stop shop for women’s reproductive and mental health.
“I was so lonely then,” said Aseel, sitting in her counsellor’s office. “I didn’t know a soul. As we had no money we had to keep moving every four months to cheaper and cheaper apartments.”
She joined 10 other women in a group therapy session led by counsellor Shiraz Nsour. Aseel was the last woman to talk. “By the time I had heard the other nine women’s stories, I already felt that my problems were not so heavy. I heard about awful cases of domestic violence.”
Counsellor Shiraz Nsour, in her office at the Noor Al-Hussein clinic in Amman, Jordan. Photograph: Tara Sutton
Nsour called her three times a day until she believed that Aseel was no longer a suicide risk, and Aseel finally felt she had some friends. “This centre saved my life,” she said, as her toddler son squirmed on her lap playing with the straps of her handbag.
“The women love to come here, they feel comfortable in the space,” said Nsour. The safe spaces allow women a level of privacy because they offer a variety of services. A woman might choose to tell her family she is going for a medical checkup when really she is going for psychological help.
“Depression, anxiety and even suicide are what I commonly see in Syrian refugee women,” said Nsour, who has been working with refugees since they began arriving in 2012. Jordan is home to more than 660,000 Syrians.
“People know about the physical need of refugees for food and shelter but they don’t consider their mental health. Many are extremely traumatised by what they have gone through in the war and then this is coupled with the poverty and uncertainty of their lives here, which leads to a lot of psychological issues.”
The future of the centre is now under threat. It receives a large part of its funding from the UN population fund, UNFPA, and is one of many in Jordan that will be affected by the Trump administration’s decision to defund the agency in April. In Jordan, that equates to a $3.2m hole in its funding this year.
At the moment, UNFPA supports 19 safe spaces across Jordan inside and outside refugee camps. In April alone, the safe spaces were accessed by 3,470 women and girls. But these services are now at risk.
“What was so great about the US funds is that they were not earmarked,” said Fatima Khan, a gender-based violence officer at UNFPA’s Amman headquarters. “It makes life much easier for us, in terms of planning to know we have funds that can be used where they are most needed.”
“We have made up most of the funding shortfall for the remainder of 2017, but beginning in 2018 the gap will be difficult to fill,” said Christina Bethke, emergency reproductive health officer for UNFPA’s Syria cross-border programme. “With competing emergency priorities all over the world, the withdrawal of a major UNFPA donor will likely mean we will need to make some hard and unfavourable choices.”
Residents of the Villa Fanny neighbourhood in Fundación, Colombia, take part in a workshop on women’s rights. The sign on the balloon reads: ‘right to life’. Photograph: Joe Parkin Daniels for the Guardian
Merlis Castro was living in a poor village in Colombia’s banana-growing region when the civil war swept through her home. Paramilitaries accused her father-in-law of collaborating with Marxist rebels of the Revolutionary Armed Forces of Colombia, or Farc.
The militiamen killed him and dismembered his body with a chainsaw. Then they stripped Castro naked, sexually assaulted and beat her. “I held my son close to my breast while they had their hands all over me,” said Castro, sitting outside the small shop she now runs.
She fled her home, and eventually found refuge in Villa Fanny, a makeshift hamlet on the outskirts of Fundación, a dusty town in the Magdalena department.
There, Castro set about rebuilding her life, with help from the Asociación Pro-Bienestar de la Familia Colombiana (Profamilia), a Colombian women’s health and reproductive rights NGO. The group, which is partly funded by the US Agency for International Development (USAid), provides classes on sexual health, self-esteem, and what to do following a sexual attack.
For Castro, the therapy was invaluable: after the attack, she had found it difficult to maintain a relationship and had separated from her partner. “I couldn’t look at my husband after what happened to me,” she said, with tears in her eyes. “Profamilia has helped all of us victims here.”
Merlis Castro received help from a Colombian women’s health and reproductive rights NGO. Photograph: Joe Parkin Daniels for the Guardian
But that help will soon come to an abrupt end. Profamilia is a member of the International Planned Parenthood Federation, which has refused to sign the global gag.
“It’s fair to say that around December our services will stop,” said María Elena Santo, a psychotherapist working with Profamilia in Fundación. “It’s a big risk because we have been working to empower the women in these neighbourhoods and make sure they are able to exercise their sexual and reproductive rights.”
Many in Fundación argue that it is unfair to destroy the wide range of social work carried out by Profamilia, simply because the organisation also provides abortions.
Fewer communities will be hit harder than the Villa Fanny neighbourhood, whose residents are almost all victims of Colombia’s half-century of civil conflict, and where many women have endured sexual violence. “They have killed our husbands and our sons, and they have raped and abused us,” said Castro, who was elected community leader last year. “We are all victims dealing with trauma.”
“They did a lot of damage to me,” she said. “I still wake up in the middle of the night unable to escape what happened.”
María Henríquez was forced from her home by paramilitaries in 2005, and now helps women in Villa Fanny to build their self-esteem. “I have worked with Profamilia, and the work has been great,” she said. “Teaching victims to respect themselves is very difficult.”
In addition to its history of violence, Colombia is affected by health issues that are prevalent in the wider region, including teenage pregnancy and high rates of maternal mortality.
In Colombia, one in every five girls aged between 15 to 19 are or have been pregnant, according to a study by the UNFPA, and Magdalena ranks among the five departments with the highest rates of adolescent pregnancy.
Fundación has one public hospital, which has been classified as among the most basic in Colombia. Staff there worry that without programmes such as Profamilia’s, unwanted pregnancies and unsafe abortions will rise steeply.
María Henríquez was forced out of her home by militiamen. Photograph: Joe Parkin Daniels for the Guardian
“We are battling with a culture that does not look at the risks of unprotected sex,” said Sofia Sánchez, the chief nurse. “Families don’t want to talk about contraception, girls worry that their father might see a condom in their handbag, and the result is that they choose to have sex without one.”
/cdn.vox-cdn.com/uploads/chorus_image/image/56560357/589989250.0.jpg)
/https%3A%2F%2Fblueprint-api-production.s3.amazonaws.com%2Fuploads%2Fcard%2Fimage%2F321088%2F0e496dca-3033-43f5-ba25-e7f4c81d70c3.jpg)
Abortion - Abortion Clinics, Abortion Pill, Abortion Information 