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In Post-Roe Alabama, the Poor Suffer Most

The West Alabama Women’s Center in Tuscaloosa, Ala., serves people from all over the mid-South (and, sometimes, beyond). One Alabama patient, Tamika (not her real name), came through the clinic in 2021 with a story that illustrates the wide spectrum of challenges facing Black women who live in states that are hostile to abortion, and how abortion stigma affects reproductive health care broadly. Tamika, who wants badly to be a mother, finds herself pregnant at a time when she knows she cannot be the parent that her child deserves. She simply does not have the resources. Her decision to have an abortion is a complex one, and it doesn’t fit neatly into any box, which makes it all the more important to consider in its entirety.

A year later, abortion care is no longer accessible in the state of Alabama. Lawmakers wasted no time after the Dobbs v. Jackson Women’s Health Organization ruling in moving to ban abortion outright. Still, the West Alabama Women’s Center stands, offering other reproductive health care that remains legal, such as contraceptive services, miscarriage management, and prenatal exams.

The importance of the Alabama clinic to the health of a woman like Tamika is made clear in this exclusive excerpt from journalists Becca Andrews’ new book “No Choice: The Destruction of Roe v. Wade and the Fight to Protect a Fundamental American Right” (PublicAffairs, on sale October 11) which chronicles the past, present, and future of reproductive rights in the United States. Prior to the Supreme Court’s decision to overturn Roe v. Wade, the landmark 1973 ruling legalizing abortion on a federal level, at least twenty-six states were already living in a post-Roe reality where abortion access was severely limited and only available to a privileged few. Andrews tells the stories of those on the ground across those states, still working to give care to those most affected by ruling. And the activists and organizations still fighting for safe, legal access to a fundamental health right.

In Tuscaloosa, Alabama, the West Alabama Women’s Center sits among a cluster of nondescript businesses that circle a moat of steaming asphalt. The faded brown brick building is set back, tucked away from the main road, wedged between a crisis pregnancy center and an insurance office. The clinic first opened in 1993, and the building gives off a sort of weary air—I’m still here. For now, the weathered white poles across the parking lot from the clinic stand ready but alone; there are no protesters pressing against them today, flailing and shouting to catch the attention of patients. The air is sticky with the rain that never fell, but still might. A rusted iron bench waits under the awning that shelters the concrete walkway leading up to steel doors. Hazy, fluorescent light leaks out from foggy, reinforced windows.

Inside, past the receptionist’s desk, in the last room on the left down a hallway lined with exam rooms, a Black woman who wants a baby sat in a plastic chair, back straight, legs crossed. Tamika has high cheekbones, a glowing complexion, and wide, expressive eyes framed by feathery eyelashes. She’s dressed comfortably for her appointment, in a black mask, black leggings, a black V-neck, and stylish burgundy Nikes. The initial shock of her circumstances has faded, but still, it seems like some sort of cruel joke that this woman who wants to be a mother so badly is getting abortion care. It’s 2021, in the final shimmery summer days of August. Hurricane Ida bore down on the Gulf Coast, causing flooding and torrential downpour in Alabama, though everyone is aware that it’s much worse to the south, closer to the water.

Rumors of too-full hospitals facing evacuation and nurses that manually pump ventilators to keep patients alive through power outages have been drifting up from Louisiana. The pandemic has crescendoed into another wave with the Delta variant, and people are beginning to realize that the vaccines won’t mean a total return to normal, in part because the basic premise of inoculation against dangerous viruses has become politicized to such a degree that large swaths of the population have refused them. An air of dread mingled with the sweaty humidity. Tamika’s employment ended in April 2020, the month after the pandemic began, and she’s been without insurance ever since, complicating her ability to access birth control. She wants to be mother on her own terms, when she feels she can provide a stable life for her child — and this chapter in which her income is sporadic, she’s uninsured, and the world is facing a pandemic that seems to be unending isn’t it. “It’s hard enough to have a baby when you’re financially stable and fully insured, but when you don’t have that, that’s a whole ‘nother level of stress,” she said. “And not only stress, it’s a whole different ballgame when you’re poor, Black, and pregnant, especially in the South.”

A decade of misdiagnosis had passed before an OB-GYN an hour away in Birmingham finally told Tamika that she had fibroids, and the lost time had decimated her egg count. Before the pandemic, she had been seeing a fertility specialist to explore her options. The visit had been expensive on its own, but when the doctor told her how much it would cost to freeze her eggs, her jaw dropped. The number has remained with her. $28,000. “Money is tight for everybody,” she says. “I don’t know anybody who just has an extra $28,000 lying around, so it was something I just had to put off. I couldn’t afford it.”

Her insurance coverage from her old job through Blue Cross Blue Shield expired in May, and after that, she tried everything she could think of to get birth control. Even if the chances of getting pregnant seemed slim, she didn’t want to take the risk and lose yet another egg. If she could get pregnant, she wanted it to happen when she could carry to term, and start the family she’d been dreaming about. She tried to get health care through the Affordable Care Act, but they wanted to evaluate her eligibility based on the previous year’s income, which didn’t make sense, now that she was no longer employed. She was denied coverage. She looked into paying for it out of pocket, but it would have set her back $185 monthly; without income, that sort of expense wasn’t realistic for her budget. Then, she reached out to the Health Department—she called and left voicemails and sent emails, but everything went unanswered, and at the time, the pandemic was escalating and vaccines were still in development. To enter the Health Department felt risky; not much was known about the coronavirus at the time, and all she knew is that people were dying and she did not want to join them.

She also contacted a local community clinic, the Maude L. Whatley Health Center, and was again met with silence. The uncertainty of the pandemic led to staffing shortages, backed up patient care, and sporadic, unpredictable hours. Next, she tried online outlets—GoodRx, that sort of thing—and at first, it seemed like it might work, but when she disclosed that she was on medication to manage hypertension, she was rendered ineligible. “The health care system has failed me,” she says.

Tamika has found some measure of reprieve at West Alabama Women’s Center, which is owned by the local abortion fund, the Yellowhammer Fund, which was able to assist her with the costs. She says the care she’s gotten through them has made her feel somewhat human again. “I thank God for this clinic,” she says, and she considers herself lucky to live in Alabama, in a city that still has an abortion clinic, rather than a state like Mississippi. Still, she cannot have what she really wants: stability, a life without the crushing fear of a global pandemic, the resources to raise a child in a safe, healthy environment where she feels she can meet all the needs that could possibly arise for herself and her family. “I don’t know if I’ll be able to get pregnant again.” Her words fall, cold and wet with grief.

To be sure, she is acutely aware that childbirth for Black women in this country is dangerous. The United States has one of the highest maternal mortality rates among developed nations, and Black women are two to three times more likely to die than their white counterparts. Her past experience with the medical system hasn’t left her feeling like her life and the lives of those she loves matter much. One close friend had an ectopic pregnancy that was ignored by her male OB-GYN; she complained of pain and he accused her of trying to get drugs from him. Tamika was worried, so she sent her friend to see her doctor in Birmingham, who confirmed the pregnancy was ectopic and rushed her new patient into surgery, where she had to remove a Fallopian tube in addition to the pregnancy that could have killed her. While she was performing the surgery, the doctor discovered that the woman’s pancreas was also in danger of rupturing. Another friend nearly died in childbirth when her baby emerged facing the wrong way and got stuck—she says the doctor used forceps to get him out, damaging his arm and causing severe vaginal tears. Her friend was hemorrhaging, and she says the doctor told her that they needed to “hurry this up”—her shift was ending, and it was picture day at her son’s school. These stories haunt Tamika, and that they all involve Black women and they align with her own experiences cannot be coincidental.

For years, Tamika was forced to endure painful heavy periods that stretched on for weeks and left her dizzy and weak. In 2008, when she was newly graduated from college and had just become ineligible to remain on her parents’ insurance, the bleeding and the cramping became unbearable. Unsure of what else to do, she went to the Health Department, where she was told that finding the right kind of birth control would help her body find a regular menstrual cycle again. For years, she cycled through different types of hormonal contraception. Nothing worked, and she increasingly felt as if she were some sort of alien, struggling to convince people of an entirely different civilization that she was in trouble and needed help. “I’m not asking for a miracle—I just don’t want you to put a Band-Aid on a bullet wound and send me out of the door,” she said.

When she got her own insurance, she thought it could be the golden ticket to finding some relief. At the very least, she could return to a doctor she was familiar with, a male gynecologist she had seen when she was covered through her parents. One day, the pain and the bleeding reached a point where she lost consciousness, and she was rushed to the hospital, where she stayed for five days. The doctors there had their own idea of how to fix it — by inserting an IUD. Even at the hospital, no one thought to check for fibroids, no matter that an estimated 26 million women between the ages of 15 and 50 suffer from them, or that Black women are two to three times more likely to develop them, and those benign tumors appear at younger ages and are greater in number and more severe than in white women. “Fibroids run in my family: it’s just something that Black women are more genetically predisposed to,” she says. “All five of my first cousins have it. My grandmother had it.”

Inside Tamika, a fibroid that she estimates was about the size of an orange had glommed on to her uterine wall. When an IUD was inserted, it irritated and inflamed the fibroid, amplifying pain that radiated throughout her body. She told a cousin about what she was going through, and her cousin sent her to the fertility specialist in Birmingham, a Black woman who quickly performed an ultrasound and diagnosed Tamika. Within three months, they had all been removed. “She saved my life,” Tamika tells me. “She gave me a return to normalcy.” The specialist who helped her wasn’t a magician — she was a Black woman who knew what to look for, because she knew other Black women were suffering and being dismissed as weak by people who could never fully comprehend the cost of living a life shaped by pain.

Women’s bodies are palimpsests of sexist medical presuppositions, influenced by and under the influence of abortion stigma. The history of bodies with uteruses being disregarded when they are ailing winds back centuries, explained away as “hysteria” or assumed weakness by the medical profession as it has been traditionally controlled by men. This attitude — that women’s bodies are defined by how men believe they should function — propels abortion stigma forward and complicates what should be a straightforward practice of basing reproductive health care on the needs and experiences of the patient. Instead of the simplicity of providing medical aid and testing in response to a patient’s self-reported symptoms, which seems so much more attainable in other arenas of medicine, people with uteruses are met with skepticism and patronizing attitudes. Tamika was forthright about her pain, and she searched for solutions, but her anguish was not taken seriously. That pattern has altered her reproductive life, her ability to have children on her own terms, her future as a parent. Her basic human rights have been violated. Abortion stigma does not just affect abortion—it leaks into all aspects of reproductive health care and education. It’s present in sex education, birth control practices and attitudes, routine gynecological care, prenatal and postnatal care, and sterilization. Katsi Cook, an elder Mohawk midwife, has written: “Women are the first environment. We are an embodiment of our Mother Earth. From the bodies of women flows the relationship of the generations both to society and the natural world. With our bodies we nourish, sustain and create connected relationships and interdependence. In this way the Earth is our mother, our ancestors said. In this way, we as women are earth.” Her words are wise and powerful; if only we were truly seen this way, if only we were treated with such respect when we seek care for our bodies.

Women of color like Tamika are often faced with institutional racism and generational trauma when they approach the medical profession with a problem, and that’s in addition to the general suspicion their gender earns them. Those ingredients concoct a potent poison that has resulted in death, for sure, but also in the loss of life in the sense that people whose bodies are biologically coded female have been unable to live their lives to their fullest potential. These paths of activism were paved precisely because women’s bodies, pregnant bodies in particular, are treated like there is already something wrong with them by virtue of their reproductive function. In our culture, “we fundamentally believe that pregnant people are worthy of suspicion and therefore control,” points out Rafa Kidvai, Legal Defense Fund director at If/When/How, a reproductive justice nonprofit that seeks to fight the criminalization of pregnancy and abortion.

It starts young. Girlhood is laden with reproductive stigma and stereotype. From the time we are children, we are taught to cosplay as mothers. Dolls are shoved into our arms, and our aspirations are molded to grow toward what patriarchal forces would have us believe is our highest calling, to bear children and raise them to continue to uphold the hierarchical structures that keep sexism and racism firmly in place. Some of us learn as children to care for younger siblings with a maternal air, to keep house, to prepare food for our families, in the unspoken service of one day being a wife and a mother in a nuclear family. When the day comes and we bleed, we are informed that we are no longer children, and that this is an important step toward motherhood. In parallel, we learn to fear our bodies and their terrible powers. So long as we are unwed, pregnancy is the second-worst possibility. Abortion is the worst.

For women of color, there is a specific element of white supremacist control to the policies that regulate their bodies. It’s hard to hear a story like Tamika’s and think anything more optimistic than that all the doctors who saw her simply didn’t care about her. They could not be bothered with her pain, her fertility, her aspirations, her autonomy. She did not have money, nor

insurance, nor light skin, nor any advocate beyond herself. Reproductive care is racialized. To be sure, the politicization of abortion affects all people with uteruses, but we cannot ignore the different degrees and nuances to who gets what sort of care and how. Black women also face an accusation that by seeking abortion care, they are committing genocide against their own people. Billboards are sold in Black neighborhoods to heavily-white anti-abortion organizations who splash them with twisted versions of anti-racism slogans: Black babies matter, and the like.

When she was walking into West Alabama Women’s Center for her first appointment, Tamika was subjected to the opinions of “two gentlemen,” as she generously calls them. They shouted at her about her baby’s heartbeat, and she suppressed her rage, but let an eye roll through her composure. “That’s fine and dandy, I know that my baby has a heartbeat,” she says, sarcasm coating her words. “I have a heartbeat. The Black men that are being slaughtered in the streets have heartbeats, too. And nobody seems to care about that.” These issues are related, whether the (most often white) people who stand outside of clinics want to acknowledge it or not. Civil rights activist Angela Davis wrote, “When Black and Latino women resort of abortions in such large numbers, the stories they tell are not so much about the desire to be free of their pregnancy, but rather about the miserable social conditions in which dissuade them from bringing new lives into the world.”

Abortion stigma infects prenatal care, when the life of a fetus—no matter how wanted, that’s not part of this conversation—becomes more important to the medical decision makers than that of the mother. In postnatal care, that is, when it exists, its shadow appears in the casual it’s-just-the-blues dismissal of postpartum depression, in our culture’s saintly, shiny portrayal of new motherhood as a state of heightened being, rather than of someone who needs support— from a partner, from the government, from a medical team. The baby has been born; pro-life mission accomplished. All done.

There are also immediate barriers to abortion care. A young Black woman I met in Huntsville named Jazmin told me that when her gynecologist confirmed her pregnancy the week prior, she told her that abortion in Alabama was illegal. That’s not true, and it’s difficult to believe anyone who practices medicine could be honestly mistaken about such a thing. As a reporter who has covered reproductive health for more than six years, I’ve heard from people of all backgrounds about what has made it difficult or impossible for them to access abortion care when they needed it. Money has consistently been the biggest barrier, especially when travel is necessary. Paid time off for their procedure and to accommodate any extra appointments required by the state due to waiting periods. Transportation, whether that’s because they share a car with several other members of their family or the bus routes in their city are unreliable or they can’t afford gas or they have to travel to another state entirely to get help. Childcare, because at least 60 percent of abortion patients already have at least one child. An abusive partner who intentionally impregnated them so they couldn’t leave once and for all. A snowstorm. A canceled appointment when the fly-in abortion provider’s flight was canceled, rendering the provider unable to get to the clinic. A mix-up in which the patient accidentally went into the crisis pregnancy center next door to the clinic, and they were kept there so long that they missed their appointment. PTSD. The crushing weight of what it means to be a person seeking abortion care in a hostile state.

That night after I met Tamika, the clock inched closer to midnight. Tamika, who asked to only go through the emotional process of telling her story once, declined to give me contact information to follow up with her, but I pictured her someplace cozy, resting as she waited for the medication to take effect and for her pregnancy to pass.Time was running out for the Supreme Court to weigh in on a new Texas law that was set to go into effect on September 1st which would ban abortion after six weeks’ gestation. The law also encouraged vigilantism among anti-abortion citizens by including a clause that said promises a $10,000 bounty to any citizen — not necessarily a resident of Texas — who reports an instance of someone “aiding and abetting” abortion past six weeks that checks out and results in prosecution.

That afternoon, I was confident that the Court would intervene. The law was clearly unconstitutional, violating the trimester framework established in Roe and the undue burden standard of Casey. Besides, they’ve always intervened in states measures that so blatantly disregarded precedent.

Alone in a featureless hotel room in Tuscaloosa, I lay in bed, refreshing Twitter over and over, feeling increasingly anxious. Midnight came and went. The law stood.

Excerpted from NO CHOICE by Becca Andrews. Copyright © 2022 by Kelley Andrews. Available from PublicAffairs, an imprint of Perseus Books, LLC, a subsidiary of Hachette Book Group, Inc., New York, New York, USA. All rights reserved.

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