This story is part of a partnership between MedPage Today and VICE News.
There weren't enough chairs in the waiting room of the Houston Women's Clinic earlier this week. So patients stood wall-to-wall, anxiously hoping to end their pregnancies before the clinic closed for good.
"The tension in the air was palpable here," the clinic's director, Kathy Kleinfeld, told VICE News. "It was standing room only. There was no parking. I've never seen the kind of volume that we've had here in the last couple of days."
Houston Women's Clinic was one of only 19 abortion clinics left in the state after more than 20 others closed in October 2013 as a result of Texas House Bill 2. The law, which requires, among other things, that abortion doctors have admitting privileges at a hospital within 30 miles of the clinic, passed even after then state senator Wendy Davis's pink-sneakered filibuster captured national attention. But a new round of closures was expected July 1, when a delayed part of the law was to take effect, requiring the abortion clinics to be ambulatory care centers with strict building requirements, such as wider halls. If the Supreme Court didn't step in, 10 clinics, including Houston Women's, would be forced to shut down.
Even if Kleinfeld and her colleagues didn't have jobs the next day, the Houston Women's Clinic staff was committed to staying late into the night so that no one would be turned away if the clinic was forced to close.
"Everyone was pretty much on edge," Kleinfeld said. "We were hopeful, but still, you still never know which way it's going to go."
But halfway through the afternoon, the Supreme Court issued a temporary block of the Texas law until it decides whether to take up the case — Whole Woman's Health, et al. v. Cole, Comm'r, TX DHS, et al. — this fall.
"It's been a roller coaster," Kleinfeld said.
The clinic told its crowded waiting room that it would remain open, and patients could reschedule their appointments for later in the week if they wanted to. Kleinfeld said she could feel the wave of relief.
But the court's stay didn't keep her patients from traveling as many as three hours to Houston Women's Clinic because closer abortion clinics had closed already. And it didn't keep them from undergoing mandatory ultrasounds and counseling before waiting for 24 hours to undergo the procedure, prompting two trips, two days off work, two days of gas, and two days of paying for childcare for their other children.
"What you end up with is that abortion is available only for those with means," said Debra Hauser, CEO of Advocates for Youth, which started the 1-in-3 Campaign to encourage women to share abortion stories to end the stigma and shame surrounding them. The campaign was named because one in three women will have abortions in their lifetime, according to the Guttmacher Institute. "When are we going to get to a point when all of this nicking away at access becomes the definition of 'undue burden'?"
She's referring to the abortion standard left undefined by the Supreme Court in 1992, when it took up Planned Parenthood of Southeastern Pennsylvania v. Casey and upheld most of Roe v. Wade, but allowed state restrictions as long as they didn't create "undue burden" on a woman. What constitutes undue burden has been debated for more than 20 years, and abortion advocates hope that the Supreme Court will define it if they take up the Texas case this fall.
Medical organizations generally want to keep medical decisions between doctors and their patients without legislative intervention, but they don't all have abortion policies. The American Medical Association says it doesn't prohibit doctors from performing abortions according to its code of ethics. And the Texas Medical association has no official policy on abortion, but has spoken out against any interference in doctor-patient decision-making.
The American Congress of Obstetricians and Gynecologists, the largest organization of physicians specializing in women's health in the United States, says "induced abortion is an essential component of women's healthcare."
"ACOG opposes unnecessary regulations that limit or delay access to care," the 58,000-member organization says in its official policy on abortion. "The intervention of legislative bodies into medical decision making is inappropriate, ill advised and dangerous."
A 2014 study in the Medical Journal Contraception found that the state abortion rate in Texas decreased by 13 percent when the number of clinics went from 41 to 22. Clinics closed, the authors noted, because H.B. 2 required doctors performing abortions at clinics to have admitting privileges at nearby hospitals by late 2013.
"Supply-side restrictions on abortion — especially restrictions on medical abortion — can have a profound impact on access to services," the authors wrote, hailing from several institutions including the Bixby Center for Global Reproductive Health at the University of California-San Francisco. "Access to abortion care will become even further restricted in Texas when the ASC [ambulatory surgical center] requirement goes into effect in 2014."
Suzy, who chose to be identified only by her first name, knows firsthand how closures affect women in Texas and said the idea of more closures frightens her.
When her local Planned Parenthood closed in late 2013 because the non-profit has faced massive defunding in Texas, she said she decided to switch from birth control pills to condoms because the next closest Planned Parenthood was 150 miles away.
But she had to make the trip anyway when she got pregnant a year later and needed an abortion.
"It was an hour and a half there, and an hour and a half back — twice," Suzy, 26, told VICE News.
She cobbled together money for gas and the procedure, but it wasn't easy. She also had to take two days off work because of the 24-hour waiting period.
"I was a nanny, so I was really uncomfortable telling my employers. So I had to lie," she said. "You're pretty much asking to get pitch-forked if you say you have an abortion in Texas and you work with children."
The first day, Suzy said she was surprised to learn she needed to undergo a transvaginal ultrasound. She said she knew it was designed to change her mind, but it didn't.
"I can't believe I could actually have an infant child with me right now," she said, adding that she's since moved to another city, gotten a better job, and isn't on speaking terms with the would-be-baby's father. "I just wish people could look at it from both sides. I understand the other side. I don't think they understand us at all. A lot of people out there really wanted me to have that baby."
Her mother probably would have been one of them, she said. Her mother was one of the protesters who would regularly hand out pro-life literature outside the Planned Parenthood before it closed.
"I recently saw a photograph on my mother's kitchen counter of a toppled Planned Parenthood sign outside a former clinic in Bryan, Texas," she wrote for the 1-in-3 Campaign. "There are plans to build a religious based crisis pregnancy center in its place. I now feel it is my duty to step up and join the fight for my right to not be pregnant and still have sex."
She wrote that she'd probably never tell her mother about her pregnancy or her abortion.
"It's really hard to sway people's views because people seem so hell-bent in what they believe," she told VICE News.