‘I feel angry and incredibly motivated’: US abortion providers consider options for fighting back

Last week, Dr Maya Bass, a family physician, was on a call with the medical director of Trust Women, one of four abortion clinics in Oklahoma. They were scrambling to figure out how to keep their doors open after the leak of a draft opinion signaling the supreme court's intent to overturn Roe v Wade and the Oklahoma governor's signing of SB1503 into law, banning abortions in the state after six weeks of pregnancy.

"With my colleagues, there's a lot of anger," Bass says. "As a medical professional, it's really hard to spend your life studying to become an expert in a certain area and then have a politician with no medical expertise and not even a uterus take away your power to offer patients safe medical care."

About once a month since 2017, Bass has traveled from her home in Camden, New Jersey, to moonlight at Trust Women Oklahoma City to help mitigate the shortage of abortion providers in the middle of the country. The tiny clinic's staff had been stretched to its limit since September, when neighboring Texas banned abortions past six weeks of pregnancy, forcing an estimated 6,000 Texans to travel to Oklahoma.

But Oklahoma will no longer be a refuge for Texan patients. A near copycat of the Texas law, Oklahoma's new ban would allow any private citizen to sue any individual - doctors, nurses, pharmacists - who "aids or abets the performance or inducement of an abortion" after signs of fetal cardiac activity. And in the aftermath of a Roe reversal, Oklahoma is one of 13 states that would immediately ban almost all abortions.

"The staff is exhausted," says Bass. "They're amazing and resilient and are probably some of the most creative humans I've ever met, in that they've been figuring out with every new legal hurdle different plans to serve as many people as possible. 'How can we legally care for patients with a 72-hour waiting period and a six-week ban? How can we pull this off?'"

They considered options for fighting back. Perhaps they could best serve patients by offering consultations and pre-screenings in their Oklahoma City clinic, then sending them to their sister clinic in Wichita, Kansas, a two-and-a-half-hour drive away, for the abortion procedure itself - but would that somehow put them at risk of being prosecuted for "aiding and abetting" an abortion? Would that implicate the Wichita clinic? Would Oklahoma City staffers be able to serve more patients if they moved to Kansas to practice there?

After her call with the medical director, Bass cancelled her next trip, which would have been in June. The clinic in Oklahoma City - which receives some 500 calls a day - has put a temporary hold on new appointments. "Patients were too nervous to schedule with us," Bass says. "We couldn't promise we'd actually be able to see them." The facility is now referring patients to Wichita. Appointments for the Kansas clinic are all currently full.

"Pregnancy is hard," Bass says. "You're tired and nauseous. People have hyperemesis - they continually vomit. Mental health disorders tend to get worse, especially during an undesired pregnancy. There are so many stories of people coming in being like, 'I can't function, I can't do my job, I've taken too many sick days.'"

After an abortion, negative pregnancy side-effects subside. But trigger laws that require patients to travel out of state to access care force more patients to stay pregnant longer. "That's an extra four weeks of suffering," Bass says. "And that is definitely something that will worsen because even if a person has resources, the clinics that exist after Roe falls will see bigger volumes and wait periods."

For doctors around the country, the struggles of patients and providers in Texas and Oklahoma offer a glimpse of what's to come after the likely fall of Roe.

"I feel sad and I feel tired and I feel angry and incredibly motivated," said Dr Katherine Farris, chief medical officer of Planned Parenthood South Atlantic in Raleigh, North Carolina. "It's stunning and gut-wrenching, but we're not surprised. We've been planning for it."

In so-called sanctuary states like North Carolina, that planning largely revolves around figuring out how already overwhelmed clinics can serve even bigger waves of abortion "refugees".

Even with efforts to bolster staffing, clinics expect increased wait times, which will force more patients to carry pregnancies past the limit for medication abortion, leading to a demand for more second-trimester procedural abortions. "So the people who say they're so upset by later pregnancy abortions are creating a scenario where more will occur," Farris says.

In a landscape rife with misinformation and stigma, where Googling "how to get an abortion" often turns up misleading ads for anti-abortion "crisis pregnancy centers", providers are preparing to educate more patients about options for safe and affordable reproductive healthcare. Even if Trust Women Oklahoma City is completely barred from providing abortions in-house, they plan to stay open, offering informational consultations and other reproductive healthcare services.

"Our patients need us as resource guides more than ever now," Bass says. "If someone calls me, it's not enough for me to say, 'Here's a number for the nearest clinic.' I need to say, 'Here's the clinic, here's the number for an abortion fund in this area if you have money issues, here's the free hotline for emotional consultations.' Healthcare providers need to serve our patients now by giving them clear resources, websites with up-to-date information."

Preparing for a post-Roe America also means providers are figuring out how to legally and ethically counsel patients on how to safely self-source and self-manage abortions.

In a pre-Roe landscape, before the advent of abortion pills, self-managing posed serious risks of injury or death. But now, "because of medication abortion, there are safe ways to manage at home", Bass says. "I'm hoping more providers recognize the safety of [self-managed medication abortions] so we can support our patients through that."

Patients may self-manage through other means, such as contacting the loose underground networks of women trained to provide safe at-home abortions outside the law, using devices such as manual vacuum aspirators made from mason jars, or herbal abortifacients, such as pennyroyal tea or black cohosh.

"I have friends in the more natural, herbal world talking about going back to the old days of using different herbs," Farris says. "Other patients will go back to physical attempted inductions. And those will be dangerous."

Even as they plan how best to handle this latest blow to reproductive health, these doctors expect their efforts won't be enough to stem the devastation of a Roe reversal. Providers are increasingly forced into interactions with patients that feel crude and absurd.

"I've had patients sitting in front of me sobbing, saying, 'Please, please, I need you to do this today,' but they didn't get their 72-hour consent," Farris says, referring to time mandated by states between counseling and getting an abortion. "Or their 72-hour consent time isn't up for five more hours, and I have to say, 'I'm sorry, I need you to wait five more hours before I hand you your pill in order to be in compliance with the law.'"

She says she has to explain to patients that though it breaks her heart, she can't make exceptions because it would jeopardize her being able to treat thousands of other women who need her care every year. She knows her work will continue to be sought out, probably with increasing desperation and a dire outlook. Research suggests that a total abortion ban would lead to a 21% increase in pregnancy-related deaths.

"There is going to be a lot of forced birth. People's lives are going to be devastated by this. People are going to be emotionally and financially traumatized. People's futures are going to be derailed," Farris says. "I will be stunned if people don't die. And it should not come down to people dying for us to reconsider autonomy."