It’s Open Season on Abortion Access, and Missouri Is Leading the Charge

Protestors standing outside of the Planned Parenthood clinic in St. Louis.
Protestors standing outside of the Planned Parenthood clinic in St. Louis. FLICKR/ PAUL SABLEMAN

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Clinic escorts wear brightly colored smocks so patients can easily see them. - KAYLA CALAC
Clinic escorts wear brightly colored smocks so patients can easily see them.

By late 2016, the pro-choice movement seemed worse off than it had ever been in Missouri. Abortion access had been steadily stripped away by politicians in Jefferson City, where Republicans controlled the House and Senate, and by November conservative Eric Greitens seemed poised to beat then-incumbent Governor Jay Nixon, a Democrat. Following the election of President Donald Trump, though, those ever-present concerns about reproductive rights in Missouri and across the country escalated into very real fears.

Desiring to help in whatever small way I could, I signed up to be a clinic escort with NARAL. I was assigned to volunteer at Hope Clinic in Granite City, Illinois, which has provided abortion care since 1974. It is one of two abortion providers located just across the river from St. Louis; the other is a new Planned Parenthood facility in Fairview Heights, Illinois.

There is no fence separating Hope Clinic and its small parking area from the sidewalk, which means that anti-abortion protestors — sometimes three busloads at a time — can stand on the sidewalk next to the parking lot as patients exit their vehicles. When that small lot fills up, some patients are forced to park in nearby lots off of the clinic's property, which means that protestors can walk right up to them as they exit their cars and trail them until they step onto clinic property. Health care providers and employees of the clinic also experience the same treatment as they enter and exit work.

To help lessen the barrage, clinic escorts, clad in brightly colored smocks, walk patients to the clinic entrance. The escorts stay mostly silent, as their role isn't to educate or influence patients — only to make them feel safe and oriented amid the chaos.

Some protesters are soft spoken, gently singing hymns or offering to hand patients flowers to engage them in conversation. Others take a more aggressive posture, barking Bible verses or medically inaccurate information in an attempt to shame them. Because clinic escorting is a volunteer program, the numbers in attendance fluctuate from week to week; sometimes the group is as big as six or seven people, other times it's just two.

You hear protestors yelling "Don't kill your baby!" and "Abortion is murder!" You see people holding infant onesies and offering them to patients, while others sing gospel songs or clutch rosaries. The most unsettling among them just stand silently, some not even holding signs, just staring ahead, their eyes fixed on patients.

Things look fairly similar in Missouri, where the only abortion provider is the Planned Parenthood clinic on Forest Park Avenue in St. Louis. Here, on any given Saturday morning, anti-abortion protesters are lining up along the edges of the clinic by 7 a.m.

Caught between the protestors and the clinic entrance are patients. Some are here for contraceptives, STI testing or treatment, breast exams and mammograms, as the clinic offers a full range of health care services. Other patients are here for abortions, having possibly traveled halfway across the state multiple times to receive care.

Last year, a slew of reproductive rights issues in Missouri made national headlines. One of the stories broadcast widely concerned the possible closure of this Planned Parenthood clinic.

In late May 2019, the Missouri Department of Health and Senior Services denied the clinic a license renewal after months of inspections. During those inspections, the DHSS mandated a new requirement for the clinic: Patients must undergo a pelvic exam at least 72 hours before a surgical abortion. (The clinic had stopped offering medication abortions a year earlier due to the same mandate being required by the state health department and deemed medically unnecessary by clinic physicians.)

The new mandate would mean that patients must undergo a pelvic exam twice in 72 hours, which doctors at the clinic — and across the country — reiterated was also medically unnecessary. In two episodes dedicated to the issue, MSNBC host Rachel Maddow described it as "state-sanctioned sexual assault."

Following the health department inspections, DHSS reported that the clinic had performed several "failed abortions," citing the care of four Planned Parenthood patients who returned to the clinic for multiple procedures. DHSS director Dr. Randall Williams also issued a statement of deficiencies reported to the clinic by DHSS — but a list of those deficiencies has never been released publicly. Instead, throughout months of legal filings and public statements, the state's health officials hammered at Planned Parenthood's refusal to force its doctors and medical staff to appear for interrogations.

The clinic filed a lawsuit on May 28 against Williams, DHSS and Missouri Governor Mike Parson to fight the anticipated license denial. The lawsuit alleges that the state essentially launched a coordinated effort to close the clinic, blowing up small problems, such as a failure to have all staff participate in a fire drill, that are "typical of the license renewal process" and a small handful of complications to make them look like widespread, critical issues. State agencies have also tried to bury the clinic under the burden of unnecessary procedures, including the two pelvic exams for patients.

"There will be times when there are complications — [it] doesn't demonstrate any systematic or systemic-wide problem," Dr. Colleen McNicholas, chief medical officer at the clinic, told NPR at the time. "Abortion is health care, and we'll continue to provide that quality health care and fight for people to have access to that."

In the months since Planned Parenthood filed its lawsuit, the two sides have fought a long and often fiery legal battle. Planned Parenthood won an early round in late June when the Missouri Administrative Hearing Commission granted Planned Parenthood's motion to stay the case and allow the license to remain active until the commission made a final decision.

In October, DHSS became the target of yet another nationwide backlash when Williams revealed in a hearing that his department had been tracking the menstrual cycles of patients at the clinic in a spreadsheet and had used that information to identify alleged "failed abortions," as first reported by the Kansas City Star.

In a statement titled "DHSS Denies False Allegation" sent to media outlets, Williams and his department defended the spreadsheet as "legally-obtained information which was required by law and which Planned Parenthood routinely submits."

By November, the licensing battle had made it all the way to Washington, where McNicholas along with other pro-choice advocates answered questions about abortion from the House Oversight and Government Reform Committee.

"My colleagues and I could not in good conscience force patients to take off their clothes unnecessarily and endure an extra, state-mandated vaginal exam," McNicholas said in her testimony. "Due to public outcry, the department relented, but that only confirms there was no medical need for the extra exams."

If Planned Parenthood's license is indeed revoked, the clinic would be forced to stop providing abortions, meaning that Missouri would be the first state in the U.S. to effectively eliminate access to abortion.

There was a time in Missouri's history, as in most states in America, when clinics offering abortions were numerous; at the height of abortion access in Missouri, nearly 30 providers were operating across the state. Anti-abortion advocates, including none other than Governor Parson, point to the falling numbers of abortions performed in the state as evidence that Missourians are "choosing life" due to "decades of pro-life leadership."

There's no denying that the number of abortions performed in Missouri has dropped dramatically in the past three decades. As of 2015, the number of abortions performed in the state was 4,765, and that figure fell to 3,903 in 2017, according to the DHSS. The historic high, by comparison, was upwards of 17,000.

Yet from the stories Mallory Schwarz has heard on the NARAL Listening Tour, it's not necessarily that more people are "choosing life" — it's that their access to abortion in Missouri has been so restricted that it has become too burdensome to receive care.

Attendees at stops on the Listening Tour have asked NARAL employees whether or not abortion is still legal in the state, confused by the chaos of last summer. In other cases, people may think that abortion access is not currently an issue, unaware that there has not yet been a final decision in the courts. In both cases, Missourians are confused about the issue.

For many pro-choice activists, including Schwarz, that has been the real success of the anti-abortion movement: Why bother overturning Roe v. Wade — the 1973 U.S. Supreme Court ruling protecting abortion without excessive government restriction — when eliminating access would achieve a similar result?

"That's their goal: adding all of these restrictions in the hopes that they will push a person far enough along in their pregnancy that they will no longer be able to access [abortion], and force pregnancy and force birth upon that person," Schwarz says. "And that's what's really amazing: What is the world that you envision for that child that you have manipulated their parents into having them? It's straight manipulation."

It's true that for decades the Republican-led fight against abortion has steadily added new barriers to access. In 1989, publicly financed medical units in Missouri could no longer perform abortions unless the mother's life was in danger. By 2005, the state passed a law requiring abortion providers to be located within 30 miles of a hospital, including in rural areas where hospitals are now few and far between.

One of the most restrictive Missouri laws concerning abortion is a mandatory 72-hour waiting period for those seeking care. After a patient's initial in-person consultation with a physician about having an abortion, the patient must wait three days before scheduling the procedure. For people who can't miss a week of work or don't have the means to travel hours back and forth to St. Louis for multiple clinic visits, those 72 hours can make a major difference in their access to care.

"The mandatory 72-hour waiting period encourages people to think about it, but they've already thought about it — no one calls if they haven't thought about it," Schwarz says. "There are people who are out there who are pretending they want what's best for these people, but they're the ones inflicting this trauma on them, and that's a really sad thing."

Such restrictions have forced some Missouri folks to travel to Kansas or Illinois, where limits on abortion are less severe. In Kansas, patients must wait only 24 hours, while in Illinois, they face no waiting period at all. Last week, Planned Parenthood released a press release outlining data showing that the number of abortions performed at the clinic on Forest Park Avenue has decreased significantly. In February 2019, 174 patients were provided with abortion care at that clinic; a year later, that number dropped to just three.

"What we've seen recently in the devastating number of Missourians being able to access abortion in their own state, is that really these legislators and appointed officials don't care if abortion is happening; they care where it's happening," McNicholas says. "It really shows that the state and the public-health system here in Missouri has completely abdicated its responsibility to meet the needs of the people who live here."

Across the river in Fairview Heights, however, the Planned Parenthood clinic there recorded providing some 96 abortions last October, the first month that service was offered. Last month, that number had jumped to 323. While the number of abortions in Missouri has declined precipitously over the years, falling to just 100 last September, the number of abortions performed at the new Illinois clinic has steadily risen, indicating that Missouri women are likely just crossing state lines for care.

"Relative to other states, we're lucky to have a haven like Illinois right there, because abortion is inaccessible in Missouri — abortion has been inaccessible in Missouri for years, especially for communities of low income, of color, LGBTQ communities and young people," Schwarz says.

In recent years, emboldened by the anti-abortion Trump administration (and the confirmation of his Supreme Court nominee Justice Brett M. Kavanaugh), nine states across the U.S. have sought to severely limit or restrict abortion access, including Missouri. These laws are likely to be appealed all the way to the Supreme Court, and with a conservative-leaning court, including Kavanaugh, they may very well be upheld.

"People are very fearful and concerned about abortion access; they've been hearing all of the misinformation and there are a lot of questions," Schwarz says. "Most people don't think about abortion until the moment that they need it, and that's why our work is so important: We need to make sure it's available and legal when they need it."

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