Delay, fear and uncertainty: How the pandemic changed access to reproductive health

Lara arrived at the Hope Medical Group for Women abortion clinic on Saturday, April 11, pregnant for the first time at 20 years old. She’d found out at 4 a.m. the Wednesday before, after peeing on a home pregnancy test and watching it instantly come up positive. 

“I think the first stage was more so panic, like, I’ve never been pregnant before,” she said.

At that point, Lara, a college student in northern Louisiana for whom we’re using a pseudonym, had no idea where she could go to get an abortion. 

“I remember getting a few pregnancy scares and looking it up, but I never dug deep enough to actually find a place in Shreveport,” she said. “I had always thought that the options were in Texas, like Tyler or Dallas.”

Gov. John Bel Edwards had shut down much of Louisiana three weeks before amidst the onslaught of the pandemic, and though she’d grown up in Shreveport, Lara didn’t know it was home to one of the longest-running and last remaining abortion clinics in Louisiana. Nor did she know that it, like the other two clinics in the state, remained open. She didn’t even know if an abortion would be possible.

She had spent the early morning hours on Wednesday searching online with her roommate for clinics in Texas, but Googling eventually led them back to Shreveport, where Hope has been providing abortions since 1980. 

She called the minute they opened and was told appointments would be three weeks away. 

By then, officials across the South and Midwest had already attempted to ban abortion access. Louisiana’s Attorney General Jeff Landry — a prominent opponent of abortion rights — had railed against the Shreveport clinic for “jeopardizing public safety” by staying open and, he said, putting profits above health. But no state had been more successful than Texas. Clinics there had already been shut down, reopened, and closed again in a series of court rulings that sent abortion seekers fleeing to other states. Shreveport’s clinic, just a three-hour drive from Dallas, had been inundated with calls and appointments. That, coupled with the clinic’s reduced capacity in order to comply with social distancing protocols, meant a long backlog of patients. 

But Lara was undeterred and eventually lucky. She kept calling back that day until staff at Hope found a space for her first appointment — the state-mandated ultrasound and counseling — on Friday. Her abortion was the next day, and she remembers an uneasy feeling in the clinic, sitting among the few chairs set 6 feet apart, everyone in masks. 

“The most memorable part was that there were still protesters outside, and they were a part of an elderly female group, without wearing masks,” she said. “And they were still berating my partner while he was driving out.”

“The question to do it or not wasn’t a question,” she said, “because I’m still in school, and I knew I couldn’t raise a child at the time.”

Pearl Ricks, Executive Director of the Reproductive Justice Action Collective (REJAC) shows the contents of a package that the collective distributes to anyone seeking information or resources. It includes condoms, lubricant, an informative zine, emergency contraception, and an early pregnancy test. New Orleans, June 8, 2020. (Claire Bangser/For WWNO)

Abortion On The Brink

The pandemic has hit more than abortion — it’s shifted access to reproductive health writ large. Advocates say patient volumes have been cut, some reproductive health clinics shut down for over a month, and even in the reopening phase, organizations are re-working how they operate. What’s unclear is the impact all this might have on reproductive health. 

Lara’s frantic search for an abortion provider coincided with the threat that, after Texas, Louisiana’s abortion clinics could be the next forced closed by anti-abortion state officials claiming the coronavirus required it. In addition to Landry, others in Louisiana had been calling for clinics to close, including Sen. John Kennedy, another strident anti-abortion politician, who deemed abortions “elective, deadly and wrong.”

Two days before Lara’s abortion, staff from Attorney General Jeff Landry’s office showed up unannounced at Shreveport’s clinic. It was the first inspection by the attorney general’s office that Kathaleen Pittman, the administrator, can remember in her nearly 30 years working at the clinic. They reviewed patient records, observed cleaning and social distancing protocols. The results of the inspection have not been made public, but the state never closed any of the three abortion clinics.

Landry said in a press release that he’d been asked by the interim secretary of the health department, Steven Russo, to create a new task force. It’s purpose: to investigate compliance with a March 21 health department notice banning elective procedures and “ensure the Louisiana Department of Health (LDH) can remain focused on fighting the novel coronavirus in our state.” 

To date the only facilities the task force publicly announced it’s inspected is one endoscopy clinic and all three of the state’s abortion clinics. 

Hope sued Landry and the department of health over the inspections — a case that was settled May 1, after the health department’s notice had already expired. 

Michelle Erenberg, executive director of the reproductive justice nonprofit Lift Louisiana, a partner in the lawsuit, said politicians “were interested in using this pandemic to try to go after abortion clinics and shut them down.”

“We had no way of knowing going into that lawsuit what the outcome would be,” she said.

Meanwhile, calls in March and April to the New Orleans Abortion Fund, which helps people pay the hundreds and sometimes thousands of dollars it costs to get an abortion, spiked in urgency, said Steffani Bangel, the executive director.

“The folks who are calling our lines are just as in need of the resources that we provide today as they were before this all started. I would say arguably even more so, considering that economic crisis that COVID-19 has brought on our community here in Louisiana,” she said.

Before the pandemic, the vast majority of Louisiana’s abortion patients were already poor, a district court found in 2017. Half had no education beyond high school, 62 percent were Black and 73 percent already had children, according to one 2015 study. Louisiana is one of the poorest states in the nation — the third-poorest, according to 2019 Census Bureau data — and the study found abortion patients lived in parishes with a higher percentage of poverty than even Louisiana’s average. Most had traveled at least 58 miles each way to get the procedure. 

On top of this, research has shown the pandemic has hit Black Americans and women the hardest. A survey from the left-leaning Data for Progress found that 45 percent of Black workers have lost jobs or had their hours cut, compared to 31 percent of white workers. And while women accounted for 55 percent of jobs lost in March and April, they made up only 45 percent of jobs that returned in May, the Bureau of Labor Statistics reported

“The calls that we are receiving are from folks with heightened needs, you know, people in our community who maybe couldn’t find full-time work before, and now they’re out of their part-time work,” Bangel said. “People in our community who are parents, who are struggling to find the resources to terminate a pregnancy when they’ve already got young children at home, who they’re now caring for all day, while also potentially working or still attending school remotely.”

As the headlines reported mass efforts to shut down clinics in many states, many were scared abortions would be banned, she said.

At the height of the uncertainty, abortion fund volunteers were “acting in many ways as abortion travel agents and abortion case managers,” Bangel said, helping clients who faced weeks-long delays at Louisiana abortion clinics travel to Alabama, Arkansas or Georgia for the procedure.

One caller went to Illinois; another to New Mexico. 

“And that’s not the goal. We’d like to keep people’s care close to home, because that’s where people feel the safest,” Bangle said. “But when the need is high and anti-abortion bureaucrats and legislators are doing everything they can to shut clinics down, folks go where they need to go to get the care they want.” 

Pearl Ricks, Executive Director of the Reproductive Justice Action Collective (REJAC) shows the contents of a package that the collective distributes to anyone seeking information or resources. It includes condoms, lubricant, an informative zine, emergency contraception, and an early pregnancy test. New Orleans, June 8, 2020. (Claire Bangser/For WWNO)

The calculus wasn’t dissimilar for advocates who help minors seeking abortions in the state. Laura Fine is a lawyer who runs the Judicial Bypass Project with Lift Louisiana. It’s designed to help minors navigate Louisiana’s judicial bypass law, which requires minors who want an abortion to gain parental consent or the approval of a judge. Thirty-six states have the same process, in which a judge determines whether a minor is mature enough to make the decision, and is doing so independently. Fine spent time researching what options she’d have if a minor came to her for help, and the clinics were closed. Could they get the procedure in a nearby state? 

“We haven’t had to do any of that, thankfully. But that was certainly all the stuff we were thinking about,” Fine said.

She did help one minor get an abortion during the shutdown, a girl who lived closer to the Baton Rouge abortion clinic, which was backed-up with appointments, and an hour-and-a-half drive from New Orleans. The minor had no transportation, and because the state mandates two visits to an abortion clinic, she’d have to find a way to make the trip twice. 

“It was just a logistical nightmare,” Fine said. 

Meanwhile, Orleans Parish Juvenile Court had imposed shifting orders, ultimately settling on remote hearings for emergency cases like judicial bypass hearings. Under law, a minor that petitions for an abortion must be heard by a judge within four days, and judges typically rule immediately, Fine said. 

In the end, the girl was able to meet with a judge, obtain the judge’s order allowing her abortion, and get to the New Orleans clinic. Fine said the New Orleans Abortion Fund paid for one trip, and the minor was able to find transport for the second. 

“But it was extremely difficult and quite expensive actually,” Fine said. 

The Judicial Bypass Project typically handles a dozen cases a year, maybe two dozen at the most, but Fine expects calls will soon start to rise. 

“That tends to happen when you have any kind of event where people get trapped at home for periods of time, where you will start seeing more unplanned pregnancies,” she said. 

Birth Control Interrupted

As abortion clinics faced a potential shutdown, some health clinics that offer reproductive care had already closed their doors, including the New Orleans clinic run by Planned Parenthood Gulf Coast, which shut down on March 13, two days after Gov. John Bel Edwards declared a state of emergency. The one in Baton Rouge remained open.

Planned Parenthood clinics normally offer a range of care unreplicated in most health clinics in the state: a variety of birth control, testing for sexually transmitted diseases and infections including HIV, pregnancy tests, abortion referrals and other care. Most services can be done in a single day, even for walk-in patients.

“We saw a lot of health clinics that do provide birth control and federally qualified health centers shutting down or severely limiting the services that they were providing,” Erenberg said. Lift Louisiana even made a spreadsheet of every clinic offering birth control and whether they were open. “There were several weeks in which a lot of the reproductive health care clinics that especially low-income people rely on for their birth control were limited in the services that they were providing.”

Planned Parenthood clinics are one of the only places that offer long-acting reversible contraception like IUD or implants, Erenberg added. 

Planned Parenthood – New Orleans Health Center on Claiborne Avenue in New Orleans. June 5, 2020. (Claire Bangser/For WWNO)

“We had to pivot,” said Petrice Sams-Abiodun, Planned Parenthood Gulf Coast’s vice president of strategic partnerships for Louisiana. 

Patients at the New Orleans clinic were referred elsewhere while the clinic was closed. She noted that some had trouble accessing birth control in bulk, because certain insurance companies only cover a month-by-month purchase. In part for that reason, the reproductive-rights research group the Guttmacher Institute has recommended that states give pharmacists the power to prescribe birth control, currently not allowed in Louisiana, as one way states can ensure reproductive health care during the pandemic. 

Instead, Louisiana politicians Bill Cassidy and John Kennedy were among 27 U.S. senators calling for the Department of Justice to investigate Planned Parenthood after its affiliates received funds through the Paycheck Protection Program. The Trump administration also asked affiliates to returned millions of dollars in funding, a move Planned Parenthood officials called a “relentless attack” from an administration that has targeted abortion rights and contraception access.  

The New Orleans clinic has reopened, but like the Baton Rouge clinic, it continues to see a much smaller patient volume than it typically would, Sams-Abiodun said. She said both clinics have expanded telehealth, and a priority has been doing so in a way that doesn’t limit access for people without an internet connection or the latest iPhone.

“The first thing that came up for me as a Black woman is the digital divide, and who’s really gonna have access to telehealth,” she said. 

Reproductive rights advocates have been arguing the pandemic shows the need to expand telehealth abortion access, too. Patients could remotely receive prescriptions for the abortion pill, something Louisiana currently bans.

The opportunity isn’t just to reach more patients amid ongoing restrictions, but potentially expand Planned Parenthood’s offering across the state, Sams-Abiodun said.

“We know that there’s so many people in central and northern Louisiana, in other places that could benefit, you know, from our health services,” she said. The organization has been scanning its telehealth data thus far to see how people are using the service and where they live,and whether its clinics could potentially help people in Monroe as much as it does those in Baton Rouge. 

This question of how the pandemic could eventually spur greater access has been on the mind of Pearl Ricks. Ricks is the executive director of the Reproductive Justice Action Collective (ReJAC), which runs the website and the Plan B NOLA project. The latter distributes free and by-donation emergency contraception across the city, state, and even country. 

It began as an anti-hierarchical, DIY project launched in 2017 aimed at ensuring minorities and those in poverty weren’t cut off from emergency birth control, which can cost between $40 and $60 at a pharmacy, and it’s since pioneered a model of low- or no-cost, accessible and grassroots pill distribution. It uses funding from nonprofits to purchase pills at a much-reduced cost — about $10 to $11 a dose. Those that can are asked to donate $10 or maybe $20, and Ricks said the organization is always grateful when people who needed it for free decide to donate a few months later, when they’re able to, “even if it’s $2.”

Pearl Ricks, executive director of the Reproductive Justice Action Collective (REJAC). New Orleans, June 8, 2020. (Claire Bangser/For WWNO)

When the pandemic hit, many of the outposts that ReJAC relies on to distribute emergency contraception were forced to shut down. Its other model of distributing pills — in which people call a hotline and get set up with a volunteer who’d deliver the pill — was stymied by stay-at-home orders. 

But as a result, Ricks said, the group has actually had to deepen its connections with other community groups and envision new ways to get medication into the hands of those who want it. 

One way has been through new partnerships; it’s now distributing pills at the CrescentCare clinic in New Orleans. Another is by piloting a contactless pickup system, where people would host pickup boxes at their houses, something ReJAC is calling “harm reduction libraries,” and ensure the boxes are regularly sanitized and stocked. 

During the height of the pandemic, ReJAC was fielding calls for emergency contraception around the country. They’ve shipped pills to Georgia, Mississippi and other parts of Louisiana. 

“Unintended pregnancies are going to spike in an environment like this, because folks are home,” Ricks said. They might be from consensual sex, but also sexual assault or domestic abuse. “Different things that people are exposed to right now, more so than ever.” 

As a result, “we’re working double-time,” Ricks added.

Plan B NOLA’s website currently lists eight pick-up spots in New Orleans, one in Baton Rouge and one in Alexandria, but Ricks said ReJAC’s goal is to create a model that could be replicated almost anywhere. It created a toolkit that takes people step-by-step through how to set up their own emergency contraception distribution network, including all things ReJAC distributes in addition to pills: a sexual health zine in English and Spanish, condoms, information on parenting and abortion resources, reproductive justice stickers.

“We’re having a conversation with multiple advocates and activists in Ruston, Louisiana, because they’re interested in starting their own Plan B networks,” Ricks said. 

“Other folks have to be having a hard time,” Ricks added. “You know, if we have a bus system that can get someone to EC, what happens in the rural places, where there is no way for them to get to anywhere else to get their EC besides like the blocks around them?”

Long-Distance Lobbying

Amid the disarray and shifting government orders — the governor recently increased capacity for businesses that are allowed to be open, and New Orleans is set to do the same on Saturday — politics haven’t stopped at the capitol. And while reproductive health has been destabilized across the state, it’s actually progressed slightly in Baton Rouge. 

This, despite what Erenberg described as a hampered ability for interest groups to lobby legislators. 

“I definitely think that it has become more challenging than it already was, which was significantly challenging, to make sure that their voices are being heard,” Erenberg said.

Lift Louisiana normally brings women to the capital to advocate for certain laws, and Erenberg is often there multiple days a week, but that’s all been scrapped amid stay-at-home orders and fears that some legislators were congregating closely and maskless at the capitol. Instead, Erenberg drafted testimony to submit to committees, watched hearings online and urged constituents to make phone calls and send emails. 

One key win of the regular session was a bill authored by freshman Democratic representative Mandie Landry that banned solitary confinement for pregnant and postpartum women in Louisiana prisons, signed by the governor on June 9. Another, by a second Democratic freshman, Representative Aimee Adatto Freeman, allows local municipalities to eliminate sales tax on feminine products and diapers.

Mifeprex, a progesterone blocker used to end a pregnancy that is less than 10 weeks along. (Robin Marty/Creative Commons)

For a body that normally advances at least a handful of anti-abortion laws every year (Louisiana passed seven in 2016), 2020 was relatively quiet. The exception is a resolution authored by Republican senator Sharon Hewitt, which declared May 2020 as “Abortion Recovery Awareness Month.” 

Erenberg said she remains worried about the long-term impacts of job losses and economic fall-out from the pandemic on reproductive health. 

“People that were getting their health insurance from their employers, losing their health insurance has obviously had a huge impact on their ability to access care,” she said. “And particularly birth control.” 

Insurance policies typically cover birth control out of pocket. “For somebody who’s no longer bringing in an income, paying $30 or sometimes up to $60 a month for their prescription contraceptives can just be completely out of reach.”

While COVID-19 has hit Black communities in the state hardest, she noted that access to reproductive health care has long had similar historic disparities along racial and economic lines. 

And she said the true impact of the pandemic on reproductive health has yet to be seen. 

“I think that we are really going to need to track this,” she said. “Researchers and public health professionals and advocates are going to need to look at this over the next series of months to really understand what the impact has been on low-income communities and communities of color of losing jobs, losing access.”