Reproductive Injustice in Texas: The Future of Health Care in the United States?

Mónica M. Alzate, PhD, LCSW, MA

Fam Med. 2023;55(2):119-120.

DOI: 10.22454/FamMed.2022.468536

“I did not just lose a pregnancy, I killed my baby,” she said with a quivering voice and teary eyes, all I could see of her face behind her mask.

As a clinical social worker in a primary care facility, I am one of thousands of health care workers in Texas affected by SB8, a law that criminalizes health care. SB8 is the last drop in a bucket that has been filling for years with restrictions to access reproductive health care. Those most affected are adolescents—particularly in foster care, low-income and rural populations, and the uninsured. But, as I was reminded in the clinic, these restrictions can affect anyone who can become pregnant.

Ms García, as I will call her, had never been to counseling, despite having had seven miscarriages since she married at age 19. She was unsure about mental health therapy, but her new family doctor suggested it. She declined a virtual appointment for privacy reasons: her son, niece, and nephew were attending online school from home.

Prepandemic, I saw my patients in a small and cozy counseling room with two large windows and three nature paintings. Many patients would comment how soothing and relaxing it was to look at a large painting of a green forest. On this day, I was in an exam room, a bigger space where floors and surfaces can be sanitized; most walls are plain, no personal touches, no comfortable couch or warm carpet—a totally sterile environment. I could see Ms García’s small and neutral eyes, her N-95 mask covering any other expression she may have made.

The evaluation revealed she was experiencing symptoms of severe perinatal depression and anxiety, conditions that, some experts argue, should have their separate diagnosis given the hormonal contribution to them. She recounted a morbid dream of being buried alive; she told her husband that if she were to die, maybe he should cut her head off to ensure her death. When asked how she got things done at home, she admitted the only reason she got up from bed was to supervise the children’s homework while her husband and sister worked. That’s when she explained that she did not have a miscarriage, but an abortion. I offered a tissue and she briefly removed her mask to dry the tears lining her face. “I did what I needed to do, but I did not want to do it. My priest told me that God will understand me and forgive me, and that I need to try to forgive myself.”

Her ordeal began at the end of her second trimester of pregnancy. Everything was going well, until she was told that her daughter “was not compatible with life.” The baby would not survive the first surgery and “would only know pain in this world.” She cried, knowing she “did not want to make her live that kind of life.” In a tone that I could barely hear, she asked herself how the tide turned so suddenly.

Although she decided to follow the medical recommendation to terminate the pregnancy, she was not prepared for the next steps. She had planned the pregnancy and desperately wanted her child to be born, and suddenly, she realized she needed an abortion. The doctors told her that because she was in her 24th week, the procedure would be unlawful in Texas. Arrangements were made to have the procedure in New Mexico, where she traveled with one of her sisters. Upon entering the clinic in New Mexico, Ms García learned that the abortion could not be completed there for reasons that were never clear to her. “They said they would give my baby an injection to kill her, but I would have to come back to Houston and finish here.”

Once in Texas, she tried to be seen immediately, but had to wait 6 days; she was told it was due to pandemic-related complications. When asked how she survived those 6 days and nights, she “barely slept, kept as busy as possible, but at night it was hard, I stayed awake until I collapsed.” As I listened to her with sadness and rage, I wondered if I could help her feel compassion for herself.

A Hispanic, devout Catholic woman who “always wanted a large family” received no mental health support before, during, or after the abortion. She was given information about online support groups for pregnancy loss, but she did not identify her experience as such. She needed mental health services not because of the abortion, but because of the conflict between her beliefs, her desire to have more children, her medical needs, and the restrictive context in which she lived.

Although the death certificate reads “still birth,” the truth lies heavy in her heart. Texas state laws keep medical doctors from doing what is medically, ethically, and humanly necessary. Texas’ maternal and child health statistics hide three facts: (1) some fetuses are indeed incompatible with human life, (2) this may only be known late in a pregnancy, and (c) people who go through this experience must suffer in silence; they simply do not exist in Texas.

For the rest of people of reproductive age with a uterus in Texas, their reproductive health care, and subsequently their mental well-being, has become more challenging since the so-called “Heartbeat Bill” took effect on September 1, 2021. This law, SB 8, effectively bans abortion after 6 weeks; it allows private citizens to sue anyone they believe has “aided, abetted,” or has the intention to aid or abet an abortion. In essence, it creates fear to discuss any matters related to abortion, referring to services, or performing the procedure. This brings me back to Ms García. Under this law, her doctors would not have been able to discuss pregnancy termination. Under SB8, Texas health care, mental health, and social service professionals face challenges to follow the ethical imperative to provide accurate information, evidence-based recommendations, and allow patients and clients to exercise their right to self-determination. In fact, we may find ourselves involved in lawsuits instead of focusing on what we do best: help people improve their quality of life. Anyone who tries to help may encounter the same fate.

One year after I met Ms García, and 10 months after the implementation of SB8, there have been media reports about pregnant persons whose lives have depended on terminating their pregnancy. They, too, had to find care in another state. At the same time, other states are implementing similar laws. SB8 is spreading like a virus, and along with other restrictive laws, it is transforming straightforward medical and mental health care into a traumatic experience. In practice, SB8 overturned Roe v Wade before the United States Supreme Court did on June 24, 2022.

I find it ironic that, as my country of birth (Colombia) and other Latin American countries have moved from complete penalization to the expansion of abortion access in the last 30 years, reproductive health care in my adopted country has been moving in the opposite direction. If the trend continues, many more providers will find themselves trapped between sound health care recommendations and the law. Consequently, much unnecessary suffering will take place, health inequities will widen, even lives may be lost, and reproductive injustice will be law in the land of the free.


Disclaimer: Opinions expressed within this essay are solely the author's and do not necessarily reflect the opinions and beliefs of the Baylor College of Medicine.

Lead Author

Mónica M. Alzate, PhD, LCSW, MA

Affiliations: Family and Community Medicine, Baylor, College of Medicine, Houston, TX

Corresponding Author

Mónica M. Alzate, PhD, LCSW, MA


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