Texas women are running out of options

This was originally posted on MSNBC.com.

There is no more birth control at the flea market. And if there ever were abortion pills, they’re long gone, too.

At the Rio Grande Valley’s biggest outdoor market, known as la pulga, locals can buy car parts and fertilizer, watermelons out of a pickup, a parakeet, an iPhone case or stickers from their favorite Mexicanfútbol team. But since this flea market was among several raided last August over suspicion it was selling abortion pills, if you even ask for birth control you’ll hear voices lower to a fearful whisper. You’ll be sent to the vendor who sells nuts, or the women selling jewelry.

On a recent afternoon, all those destinations were a dead end.

“Not anymore,” a woman whose table bore aspirin and homeopathic remedies said in Spanish. She shrugged. “Obama wants us to have more babies.”

“Go to Mexico – or stay pregnant.”

In fact, it wasn’t the federal government that raided four flea markets’ thriving illegal pharmaceutical trade, making undocumented residents that much more terrified to shop in them. The Sheriff of Hidalgo County, who took the lead, didn’t find any abortion pills, but he did charge nine people with selling prescription-drug contraband like diet pills and Viagra from Mexico. (The border is just minutes away.)

It had been a month-long investigation, Sheriff Lupe Treviño told local press.

The arrests came a month to the day after a front page New York Times story about how the state’s new omnibus law restricting abortion – the one Texas state Sen. Wendy Davis famously tried to block – was expected to close the Rio Grande Valley’s two abortion clinics. Locals told the paper that with the nearest clinic now 250 miles away, more women would terminate their pregnancies on their own by taking black-market abortion drugs. Such pills, known as misoprostol, are readily available over the counter in Mexican pharmacies. But a trip across the border would cost the undocumented much more.

“The only option left for many women will be to go get those pills at a flea market,” local organizer Lucy Felix had warned.  

For many reasons, women had already reportedly been buying pills at flea markets to end their pregnancies – because it was cheaper than going to a clinic, because they feared immigration authorities, or perhaps because they assumed abortion in the U.S. was illegal, as it is in Mexico. They also went to the flea markets for contraception, like birth control pills or injectable Depo-Provera.

As expected, the two local abortion clinics were shuttered in March under the new law – clinics that together performed 2,634 abortions in 2011. And the flea market raids had done their job. There are no abortion pills there, and no hormonal contraception.

The combined crackdown by state and local authorities in Texas has done more than make it harder for the women of the Valley to get an abortion. They’re now having trouble getting any reproductive health care at all, since the same state legislature that shuttered the abortion clinics also slashed family planning funds and closed family planning providers. And Texas’ refusal to expand Medicaid means itsdistinction as the uninsured capital of the United States isn’t going anywhere anytime soon, making the state’s broader health care crisis even worse. 

At la pulga, a woman whose stall had just barely survived the raid had one more idea for obtaining abortion pills. 

“Go to Mexico,” she said. “Go to Mexico – or stay pregnant.”

 —

“If I hadn’t planned, I would have had at least 8 kids.”

Marlena, 32, knew all about the raids on la pulga, because that’s where she used to buy her birth control. On a recent Wednesday, most of the women visiting the local San Juan Community Center, where Planned Parenthood has managed to keep open a once-weekly health clinic, had heard about the raids. Some of them said they had always been afraid to buy contraception there, because who knew how long the drugs had been sitting out in the sun?

Marlena said the drugs available at the flea market were just as good as those that her friends sometimes buy for her at pharmacies in Mexico. (She is undocumented.) The only trouble she has is finding someone to inject the Depo-Provera. “No one ever wants to do it,” she said. “They’re afraid of messing it up.”

Claudia, also 32, shook her head. “It’s better to be checked by a doctor,” she said. But she hadn’t seen a doctor since the birth of her youngest three years ago. She’d come to the clinic this time for a breast exam and a pap smear.

“If I hadn’t planned, I would have had at least eight kids,” said Marlena. The youngest of the four children she does have clambered at her feet. “But sometimes you have the money, and sometimes you don’t.” Her husband is a carpenter, and when it rains, there is little work.

It had taken both of them months of calling to get an appointment at the clinic. That Wednesday morning, a four-hour wait past the scheduled time to see the single nurse practitioner wasn’t a surprise. The women patiently juggled each other’s babies on their laps. Quiero cuidarme, they said of their need for birth control. I want to take care of myself.

Much as they’ve tried, they haven’t always been able to do that. One woman at the clinic has nine children. Both Claudia and Marlena want to get their tubes tied, but neither can afford it. “I’ve been on the waiting list for two years,” Marlena said.

In 2010, Planned Parenthood of Hidalgo County, which covers much of the vast Rio Grande area, saw 24,000 patients, including at the San Juan center. Then came the Republican legislature. 

“Sixty-six percent of the funds were slashed completely and given to other programs that don’t do family planning – worthwhile programs, but they’re not for women, especially not poor and uninsured women,” said Patricio Gonzalez, the CEO of Planned Parenthood of Hidalgo County. 

That funding cut was followed by state legislation, heralded by Gov. Rick Perry, intended to stop Planned Parenthood from receiving any public funds. The Hidalgo County affiliate had never provided abortions – in fact, public health experts estimate it had prevented between 1,000 and 1,500 abortions a year with its family planning services – but it was doomed by its connection to national Planned Parenthood and its willingness to make referrals to Whole Woman’s Health, the now-shuttered abortion clinic in town.

The family planning money that was left after the funding cuts was divided into three tiers that put Planned Parenthood and other explicitly-pro-choice providers at the very bottom, even though none of the funds were going to abortion services. The county health departments and federally qualified health centers that were supposed to replace Planned Parenthood are already overwhelmed by providing primary care, and they don’t specialize in family planning.

“They’ve destroyed the infrastructure we had here for healthcare,” said Gonzalez. “To cut out the family planning funds was a very cruel thing to do.”

In all, the clinic had to lay off more than half its staff and cut its patient load in half. By October 2011, four of the eight health centers the clinic ran were forced to close.

A small trickle of funds has since been restored through the federal government’s Title X program, which granted $1.1 million for the Rio Grande Valley through a new state association.

“I believe they did not like that the state was taking away access from women,” Gonzalez said of the federal government’s decision to bypass the state.

On top of the uphill struggle to provide basic services like contraception, cancer screenings, and testing for sexually-transmitted infections, Gonzalez is looking to help women who need an abortion. He and his staff have been trying to find an abortion provider who has local admitting privileges at a hospital within 30 miles – the requirement the state imposed last summer, even though major medical organizations say it has no basis in medical necessity and is only meant to shut down safe clinics.

“To cut out the family planning funds was a very cruel thing to do.”

And that’s exactly what happened. Both Whole Women’s Health in McAllen and Dr. Lester Minto’s clinic in nearby Harlingen tried to get those admitting privileges, but were both forced to close after being unable to comply. (Many hospitals didn’t even bother to respond to the clinics’ requests, said Fatima Giffords of Whole Woman’s Health.)

If nothing else, Gonzalez hopes to add a doctor for miscarriage management and to treat women who self-induce an abortion and are still bleeding. Those women used to go to the abortion clinics when their attempts to end their pregnancy on their own failed. One study found that women in the Rio Grande Valley were far more likely than other women nationally to self-induce – 12 percent, compared to the national average of 2.6 percent. And that was before the legal clinics closed.

“It worries us a lot,” said Lucy Felix, a field organizer in the Valley with the National Latina Institute for Reproductive Health. “They will find a way to acquire that service, so it’s important to us that there are safe clinics for them to get care.” She knows the stories of women self-inducing – “they are very sad, but I can’t tell them.” 

The fear isn’t just breaking the fragile trust of the women who come for health and education – it’s that the women could even be prosecuted.

These women are already struggling to get basic health care services, Felix pointed out. She was taking a break from a baby shower at a colonia, one of many unincorporated settlements where the poverty can be desperate.

“Many colonias don’t even exist on the map,” she said. “The GPS can’t find them, so how can programs and resources?”

— 

Where there is scarcity on the Texas side, there is abundance in Mexico – for those who can move freely, and for those who can pay.

On the way to the bridge to Nuevo Progreso, a gringo shopping paradise just across the border, the road bends through orange groves and fields growing onions and sugar cane and cabbage. Just before the crossing is the county building where Planned Parenthood had to shut down its operations – the rare clinic that was walking distance from two colonias.

She has spent her life on both sides of the border, though she was born on the U.S. side. When she was 25 and living in Reynosa, Mexico, just across the border from McAllen, a friend’s husband asked Dora to accompany his wife to a doctor for an unnamed service. Dora didn’t know what the doctor’s visit was for, but was alarmed to hear her friend screaming on the other side of the door. “The anesthesia didn’t take,” the nurse told her. It was an illegal abortion.

Years later, Dora accompanied a young woman to Whole Woman’s Health in McAllen – a rape survivor who asked Dora to come because she had no one to go with her. This time, the procedure was legal and safe. 

Across Latin America, the availability of the abortion drug misoprostol, packaged by Pfizer as Cytotec and officially intended for ulcers, has been a game-changer for women who want to end their pregnancies without surgical intervention. The drug carries risks, but nothing like older and more violent means of self-inducing.

“The mortality rate has dramatically decreased because women have been able to buy misoprostol on the black market,” said Kirsten Sherk, a senior advisor at Ipas, which works on access to safe abortion internationally.

Even though the illegal abortion market has gotten safer, it’s hardly a substitute for a doctor’s care. Misoprostol is the first part of the two-pill regimen legally available in U.S. clinics for a medication abortion, but using it without a doctor’s supervision can be dangerous.

“The risk is that a woman isn’t screened for eligibility – how far along she is in pregnancy, or whether it is one of the rare situations where it’s not recommended,” said Dan Grossman, vice president of research at Ibis Reproductive Health. “Another risk is that she doesn’t get follow-up care to know that it’s complete. Misoprostol used alone even in the recommended regimen is 85 percent effective in the first trimester of pregnancy.”

An incomplete abortion can cause septic infection or even death. And taking the drug is far less likely to be successful if the pregnancy is advanced.

Near McAllen, rumor has it there is still an illegal abortion provider – a doctor on the Mexican side in Reynosa – for women who are more than three months pregnant. But Dora said the trip there is too dangerous because of warring drug cartels in the area. “Everyone is armed,” she said. “It’s like you’re walking in Nicaragua or something.” 

The scene is far different in Nuevo Progreso. Moments after crossing – the way out of the U.S. is easy – a sign says, “Welcome Home, Winter Texans” and urges them to try some cut-rate dental. This is a medical tourist Disneyland, everything planted on a thoroughfare of retirees plodding in khaki and kicking back Coronas.

Here, liquor stores are also pharmacies. Jewelry stores are pharmacies. Even street carts, with cardboard paste-ups of the most popular prescription drugs, are pharmacies. “Don’t let your gun get rust,” cautions one of the many hand-written signs for Viagra.

Though some drugs technically require a prescription in Mexico, no one here makes a pretense at it. Hormonal contraception is easy to get – Depo Provera was only $10 for a three-month dose at one pharmacy – and misoprostol, the abortion drug, is almost as easy. No one even has to pretend to have an ulcer – the preferred phrase is asking for a pill para que baje, or para que venga – to bring back your period.

“I’ve never sold it for ulcers, I’ve always sold it for abortion,” a middle-aged male pharmacist said bluntly.  

He said he had been seeing one or two people a week cross the border from the U.S. to buy it, a little more since the Texas clinics closed. Three out of five pharmacies msnbc recently visited sold misoprostol freely, though the price varied widely, from $59 for a generic to $170 at one pharmacy for the Pfizer brand.

They also gave wildly different instructions on dosage. (Women on Waves, an advocacy group that provides clandestine abortions where it is illegal, hasinformation about taking the drug safely on their website – its Women on Web service even allows pills to be ordered online from a doctor in a foreign country, but it takes weeks and requires an internet connection.)

How many pharmacies were there on this strip? “One hundred and eight,” grinned a street hawker.

But for the undocumented living illegally in the U.S., accessing health care on the Mexico side means either making the treacherous crossing back or, more likely, encargar a alguien – paying someone with papers to visit the pharmacy. That takes money too, and people are nervous. 

Few expect things in Texas to get better any time soon. Planned Parenthood took the state to court over the loss of its family planning funds, a case that’s still pending, and Whole Women’s Health abortion clinic is challenging the admitting privileges requirement. But both depend on the conservative Fifth Circuit – or perhaps the Supreme Court – to eventually step in.

“I’ve never sold it for ulcers, I’ve always sold it for abortion.”

For now, local women are trying to take care of themselves.

Dulce, 21, and another visitor to the San Juan clinic, crossed the border from Mexico while pregnant. It had taken a month for her and husband to get through. They had wanted to get to North Carolina, where they heard they could find work, but she was too exhausted from the journey to get that far, so they moved to a mobile home in the Rio Grande Valley. She had come to the clinic for a free IUD after months of trying for an appointment.

She had wanted to get on birth control after her first baby was born. “I didn’t know about this clinic,” she said. She and her husband, who works in construction, began saving for an IUD, which cost hundreds of dollars at other clinics. While they were trying to come up with the money, she got pregnant again. It had only been eight months after her first was born.

She gestured at her three-month-old and smiled. “We ended up using the money for her.” But there isn’t much left.