Another disaster: Access to abortion after Hurricane Harvey

Abstract

The devastating effects of natural hazards uncover and exacerbate social inequalities, yet reproductive health outcomes are often overlooked. Despite a small but growing literature on gender and disaster-related impacts, there are no studies to date to our knowledge on the intersection of abortion and disasters, which is important because abortion is common in the U.S. and is a critical component of comprehensive reproductive healthcare yet is routinely inaccessible due to a lack of health insurance coverage and other policy barriers. This is a qualitative case study of 8 individuals who required abortion services in Texas at the time of Hurricane Harvey. The study sample comes from caller data from a local Texas abortion fund. We present caller demographics, which reveal nonwhite patients in later trimesters struggling economically. Callers display a need for funding, particularly for travel, and were affected by interpersonal and sexual violence. We conclude with policy and research implications for disaster planners, domestic violence organizations, state and federal officials, and health insurers.

The devastating effects of natural hazards uncover and exacerbate social inequalities (Elliott & Pais, 2006), which is problematic because weather-related disasters are increasing in both frequency and severity (Vose et al., 2017). However, the outcomes of disasters are not completely out of human control; they are shaped by institutions, technologies, and social processes (Tierney, 2014). Although researchers have repeatedly documented the disproportionate impact that disasters have on marginalized populations (Enarson et al., 2018; Thomas et al., 2013), policy-makers in the U.S. have yet to fully address the unique needs and vulnerabilities of these groups. As one important example, large-scale weather-related disasters frequently disrupt lives and infrastructure for weeks or months, but the need for common medical procedures such as abortion continues, and may even intensify. And yet, sexual and reproductive health remains marginalized in disaster studies.

This is a qualitative case study content analysis of 8 individuals who required abortion services in Texas at the time of Hurricane Harvey. Despite a small but growing literature on gender and disaster-related impacts, there are no studies to date to our knowledge on the intersection of abortion and disasters. We briefly outline the current related literature, explain the context of abortion services in Texas, describe our sample from West Fund, a local Texas abortion fund, and outline our results that find the need for funding, particularly for travel, and the role that interpersonal and sexual violence plays. We conclude with policy and research implications.

Women and disasters

Social theories of inequality demonstrate “that one’s location in the social strata often determines one’s life experiences, relationships, opportunities and overall life chances” (Fothergill & Peek, 2004, p. 90). In short, individuals have differential vulnerabilities and the physical, social, financial, and psychological impacts of disasters are shaped by individuals’ intersecting social identities. Marginal groups, such as women, suffer some of the most severe disaster-impacts due to their low-status (i.e. they have fewer resources) pre-disaster (Moreno-Walton & Koenig, 2016; Thomas et al., 2013) and they tend to be more often overlooked post-disaster (Callaghan et al., 2007; Cerdá et al., 2013; Davis & Rouba, 2012; Horton, 2012; Leyser-Whalen et al., 2011; Oxfam International, 2005; Thomas et al., 2013; Zotti et al., 2012). Some of these inequalities stem from biases in larger societal structures that result in fewer resources and fewer choices for more vulnerable populations.

Although much of the literature review below discusses the vulnerability of marginalized populations, it is not our intention to paint them as inherently vulnerable. For example, although women’s social statuses and caregiving responsibilities can, and often do, create added vulnerability, women are often the first to collect resources, organize post-disaster relief, and engage in various forms of informal disaster leadership, even when governments fail to include them in their decision-making processes (Chew & Ramdas, 2005; David, 2012; Enarson, 2001; Peterson & Krajeski, 2012).

As Enarson et al. (2018) state, “Gender stereotypes affect disaster services and emergency operations,” and there is “gender bias in the design, funding, implementation, monitoring, and evaluation of emergency shelter … healthcare, and other post-disaster initiatives” (p. 132). For example, shortages in medical care both pre- and post-disaster more strongly affect more vulnerable groups such as women, particularly low-income women of color (Kates et al., 2006; Klinenberg, 2002; Leyser-Whalen et al., 2011; Sharkey, 2007). Moreover, poorer individuals are more likely to depend on community-based services such as public transportation and healthcare (Enarson et al., 2018; p. 133) and thus the lack of these services affects these individuals’ health and safety (Enarson et al., 2018).

Disaster researchers focused on women have looked at ways that natural hazards adversely affect women such as documenting poor mental health outcomes (Frankenberg et al., 2008; Galea et al., 2007; Hirth et al., 2013; Laditka et al., 2010; Priebe et al., 2009; Brown et al., 2010), sexual violence (Alam & Rahman, 2014; Bayard, 2010; Carballo et al., 2006; Logie et al., 2017) and intimate partner violence (Harville et al., 2011; Sloand et al., 2017), with a few studies focused on reproductive health such as pregnancy and birth (Monteblanco & Leyser-Whalen, 2019; Monteblanco & Vanos, 2020; Richter & Flowers, 2008), infertility (Liu et al., 2010; Richter & Flowers, 2008), contraception (Berndt, 2018; Kissinger et al., 2007; Leyser-Whalen et al., 2011), and menstruation (Alam & Rahman, 2014; Stockemer, 2006). To our knowledge, there is no literature on the junctures between disasters and abortion.

Abortion

Abortion is an important area of study because abortion is common in the U.S. and is a critical component of comprehensive reproductive healthcare, yet is routinely inaccessible due to federal and state policies (see below), as well as not being covered by most health insurance plans. A large proportion of those seeking abortion pay for the procedure out-of-pocket and are simultaneously below the federal poverty level (Ibis Reproductive Health, 2016). The average cost for an abortion in the first trimester ranges from $500–675, going up to a range of $825–2500 in the second semester and $750–5000 for a third trimester abortion (Jerman & Jones, 2014; Jones et al., 2013; Jones & Finer, 2012; Shattuck, 2017). These costs are substantial because the majority of abortion patients are not financially stable (Ibis Reproductive Health, 2016) and have fewer resources to identify early pregnancies, afford safe and timely abortions, and/or travel and stay in a town hundreds of miles away from home (Colman & Joyce, 2011; Gerdts et al., 2016; Gold & Hasstedt, 2016; Jones et al., 2013). Furthermore, the ranges presented above do not include associated costs, such as childcare, lodging (Jones et al., 2013), and travel, which are often necessary because many towns in the U.S. do not have nearby clinics and there are 24 h waiting periods between the required first and second visits in some states (e.g. Karasek et al., 2016). These barriers are exacerbated during weather-related disasters and can also delay abortion care, which further elevates cost and procedure risk (Bitler & Zavodny, 2001; Jones et al., 2010; 2013; Joyce & Kaester, 2001), although abortions are low-risk procedures.

Beyond financial constraints, access to safe abortion has been under legal and cultural attack in the U.S., particularly in some Southern states such as Texas, waged through tactics such as Targeted Regulations of Abortion Providers (TRAP) laws (Gold & Hasstedt, 2016; NARAL., 2018), such as requirements for clinic physicians to have admission privileges to local hospitals and clinics to have mini-hospital infrastructure. Although these laws were eventually overturned by the Supreme Court in 2016 (Arons, n.d.), they resulted in clinic closures over the past 25 years throughout the state of Texas. In 1992 there were 79 clinics, in 2000 there were 65 clinics (Finer & Henshaw, 2003), in 2014 there were 44 clinics, and most recent numbers for 2017 show 35 clinics (“State Facts,” 2019). To place these numbers into context, twenty-nine million Texans (Population USA, n.d.) reside in a state that is approximately 800 miles/1287 kilometers long and 800 miles/1287 kilometers wide (Hlavaty, 2014). The 35 facilities in 2017 were located in only 4% of the 254 counties in Texas (Jones & Jerman, 2017). There are also fewer clinics that offer later gestation abortions, thus those later in their pregnancies are more likely to have to travel.

There have also been a steady stream of other anti-abortion bills (Grossman et al., 2014; Texas Tribune, 2017). For example, Texas has enacted many state-level restrictions, such as banning clinic abortions after 16 weeks gestation (or up to 20 gestational weeks at an ambulatory surgical center or hospital), and requiring that patients get a sonogram and read information that presents the possibility of adoption and describes medical risks and stages of fetal development. After the sonogram, patients have a 24-hour waiting period before they can obtain the abortion, and both appointments must be with the same physician. Furthermore, Texas laws prohibit insurers from covering abortion expenses as part of a health plan, and military insurance and Medicaid (public insurance) can only give coverage in cases of rape, incest, or a life-threatening situation (American Civil Liberties Union Texas [ACLUTX], 2019).

Hurricane Harvey also introduced more access issues. Several abortion clinics that were still open after the passage of anti-abortion laws, such as HB2 (passed in 2013) that reduced women’s access to medication to induce abortion by 70 percent and closed more than half of the state’s clinics, closed temporarily due to the Hurricane. One clinic in San Antonio raised funds for no-cost abortions for Harvey survivors (Think Progress, 2017)— but that was apparently not enough for the demand. In an August 31, 2017 email message that West Fund received from another Texas abortion fund, the Lilith Fund, stated that they heard from many callers who had appointments at clinics that closed due to the Hurricane. They also reported that callers encountered increased wait time and cost. Personal communication from West Fund stated that Fund Texas Choice, which funds abortion-related accommodations and travel associated with visiting a clinic, temporarily closed their doors at the end of 2017 because they ran out of money.

Anti-reproductive rights policies affect access to abortion services for all people, yet disproportionately affect marginalized populations who have fewer resources. Abortion access is an issue not only to avoid an unplanned pregnancy and its associated costs, but also access in a timely manner—safety and quality are improved, and costs are reduced, when abortion is performed as early in pregnancy as possible (Foster et al., 2008).

For individuals who need help with abortion costs, charitable organizations known as abortion funds provide assistance. West Fund (www.westfund.org) is an El Paso, TX based nonprofit organization affiliated with the National Network of Abortion Funds (NNAF) that provides information, local programming, community building, and gap funding for those in need of economic support to obtain an abortion in the form of a clinic voucher, otherwise known as a “pledge.” West Fund started in 2014 and has Spanish-English bilingual volunteers to take phone calls from individuals seeking a voucher at one of the area abortion clinics with whom West Fund collaborates. Of those individuals who used their voucher, the average distance traveled to a clinic was 273 miles/439 kilometers despite the mode being 0 miles (those residing in El Paso, TX and using a clinic in town). Intake managers field phone calls, evaluate applications submitted online, and assess potential patient need based on gestation and if the individual can get to a clinic they work with. Sometimes West Fund will contribute to another fund in another area with a “solidarity pledge.” Based on the organization’s current monthly budget, the intake managers allot a certain dollar amount to qualified individuals (those close enough to reach a local clinic, who are pregnant, and desire an abortion) in the form of a voucher at a nearby clinic.

West Fund callers offer an interesting sample to study because in general, information about individuals who have abortions is limited (Jerman et al., 2016) and almost exclusively comes from abortion clinic data. Studies of abortion funds are even more limited. Bessett et al. (2011) collected data from Massachusetts funds and Ely et al. (2017a, 2017b, 2017c, 2018, 2020) derived data from a Florida fund and NNAF, which consists of data from people nationally who received financial assistance from NNAF’s national fund. Our West Fund data not only contribute to this small amount of work on abortion funds, but also spotlight regional issues.

As the researchers were qualitatively analyzing the notes/comments fields where West Fund intake personnel entered any additional information, we noticed mention of Hurricane Harvey. The hurricane struck Houston, TX, which is 746 miles/1201 kilometers away from El Paso, TX, on August 25, 2017. Hurricane Harvey was a Category 4 hurricane that lingered overland for days, releasing an unprecedented amount of precipitation on the greater Houston area (Risser & Wehner, 2017). High winds and widespread flooding caused extensive damage to homes and critical infrastructure throughout Southeast Texas; in fact, some neighborhoods remained flooded for weeks (Jonkman et al., 2018). Approximately 22,000 residents were rescued from floodwaters and more than 156,000 homes were destroyed (Shultz & Galea, 2017).

Materials and methods

The University Institutional Review Board determined this study to be “exempt.” We obtained West Fund’s de-identified (no names, phone numbers, or emails) intake EXCEL sheet that consisted of information on every individual who called the fund or entered their information on the website, regardless of whether they received, or used funding. This was accomplished by the first author having a long-standing relationship with West Fund. Data were available from December 2014-February 2018, and September 2018-April 2019 due to West Fund bookkeeping. We were limited by the amount and types of data in the database; in other words, we worked with the information that the West Fund decided to collect, and who decided to enter what information. Consequently, there were a lot of missing data. We removed duplicates and the final sample size of the EXCEL sheet was n = 2,285. The number of people, however, who had any notes/comments entered was n = 759. The sample size for the Hurricane Harvey callers was n = 8.

Given our sample size, we are using the case study as our analytic methodology. A process of reflection and critical analysis marks a good case study (Jones, 1997). Stake (2000) argues that the case study offers unique and interesting information for its own sake, yet also acknowledges that case study researchers explore the degree to which the findings are meaningful beyond the case being studied, and thus their data have implications elsewhere. Case studies should reveal the nuances of each case, including contextual aspects such as historic, economic, political, and legal factors (Ritchie, 2001).

We performed qualitative coding in the form of a content analysis on the notes/comments sections. We utilized the constant comparative method (Glaser & Strauss, 1967) through comparison of respondents’ quotes to each other to develop thematic categories in which they were placed. The thematic concepts that emerged from our analyses were financial need and interpersonal violence. We present these themes in the manuscript where respondent quotes are given for illustrative purposes. Demographic frequencies and frequencies of responses are also presented for context.

Results

We tabulated basic quantitative demographic results. All eight callers contacted West Fund in the year 2017, with most within the first 6 weeks of the hurricane (Aug 30, Sept 7, 16, 24, Oct 1, 5, 10, and Dec 14). Six of the respondents live in the Houston area, one in Corpus Christi, TX (a beach community 211 miles/340 kilometers away from Houston), and one is now living in El Paso, TX. Three women were in their first trimester, 4 in their second trimester, and 1 in their third trimester. The minimum amount of gestational weeks was 4, the maximum 28 weeks, with a 15-week mean. Half of the respondents had information on family size, race/ethnicity, and age. All of these people had at least 2 kids (including blended families). Two respondents reported being Hispanic and 2 reported being African American. People’s ages were 24, 26, 28, and 35 years old.

Six women reported insurance statuses-three reported no insurance, and the other three had insurance that does not cover abortion (Texas Medicaid and military TriCare). Half of the women in the sample were given pledges (half were not given pledges) of the following amounts: $75, $300, $350, and $350. These did not cover full procedure costs from data that were available for 6 of the 8 callers: $540, $580, $650, $1600, $7500, and $9800. The other two callers were out of the service area and thus West Fund did not work with them and does not have a record of their procedure costs. Only three women reported that they had other resources that they could draw on to cover some of the gap funding, the range being between $100-$1000. Three of the four women who reported “employment status” reported being unemployed, the other reported being in the military.

Only one person was reported as having used their pledge, traveling 884 miles/1423 kilometers from Houston, TX to Albuquerque, NM. This individual was the furthest along gestationally at 28 weeks and also received a NNAF contribution and funding from the clinic. Half of the callers indicated that they had contacted other abortion funds, yet the aforementioned woman was the only one who had successfully received other funding at the time of the West Fund call.

Themes that emerged from the qualitative analyses were first, the need for funding for abortion-related costs, particularly travel, and second, violence, which included domestic violence and rape.

Need for funding

All callers stated that they were displaced by the hurricane, which probably exacerbated the need for funding, in addition to not having insurance, being unemployed, and/or not having adequate personal resources to cover costs. Five of the 8 callers were in their second and third trimesters. Based on both caller and clinic locations, all callers had to/would have had to have traveled over 700 miles/1127 kilometers to reach an available clinic.

Violence

For only 8 cases in the sample, domestic violence and rape (n = 3) stood out as a theme to the researchers. Two women reported being raped, one in a disaster shelter, and the other woman was going to continue the pregnancy but then decided against doing so after the hurricane uprooted her life. Another woman reported being in a “dangerous situation,” that she had a restraining order against an abuser, and was separated from her partner due to domestic violence.

Discussion

Demographically, the individuals in our study mainly reflected the national abortion clinic sample data in that they all had existing children (Cohen & Joffe, 2020) and the majority were in the 20–29 year old age range (Jerman et al., 2016). Of note, however, our sample had a higher rate of racial-ethnic minorities compared to national clinic sample data (Jatlaoui et al., 2019). Our sample demographics also represent those more affected and most vulnerable to environmental hazards (Cutter et al., 2003). We believe that our results reveal both the economic and racial injustices inherent in abortion access and in U.S. disaster policies.

The West Fund disaster sub-sample also differed on another key variable—trimester– compared to both the larger West Fund sample and national abortion clinic data that indicate that 90+% of abortions in the U.S. occur in the first trimester (Centers for Disease Control, 2016; Jatlaoui et al., 2019). This suggests that most abortion patients desire termination in the first trimester. People who are bordering or past the gestational limit cutoff tend to have significant and multiple hardships (Ely et al., 2017c). The aftermath of a natural disaster is one such hardship, due to major life disruptions that create an environment of prioritization of basic needs such as food and shelter. Moreover, research has shown how disasters disrupt social networks (e.g. Laditka et al., 2010). Thus, the hardships faced by the people in our sample may have been exacerbated by not having the usual social networks to rely on for help with matters such as transportation and child care, due to those in their social networks having been displaced and/or facing the same post-disaster hardships.

Other disaster-related hardships in obtaining an abortion were related to area abortion funds running out of money and abortion clinics temporarily closing. Moreover, few clinics offer later-term abortions, and many of these callers were in their 2^nd and 3^rd trimesters. As such, individuals called a fund for a clinic 700 miles/1127 kilometers away from their homes. This is important to note, yet researchers in the area of reproductive justice and disasters have so far overlooked this need for pre- and post-disaster planning.

Regarding our qualitative themes, our finding for the need for funding was unsurprising given the circumstances outlined above. Aside from times of crisis or disruption, finding the means for an abortion remains the biggest obstacle for U.S. women (Cohen & Joffe, 2020). In the U.S., women, compared to men, are more likely to be poor, and as such, struggle more post-disaster to secure housing and financial stability. Abortion is another resource they are struggling to access; reminding us that disasters often reveal and worsen women’s economic insecurity.

What was more unexpected were our findings on the theme of violence, including in a disaster shelter. Humanitarian relief agencies, other disaster responders, and social scientists have all documented that women are at risk of physical violence in the aftermath of disasters ( Bayard, 2010; Carballo et al., 2006; Enarson, 1999; Enarson et al., 2018, p. 135 ). More specifically, international disaster researchers have documented sexual violence in disaster shelters themselves (Alam & Rahman, 2014; Bayard, 2010; Carballo et al., 2006; Logie et al., 2017). Less has been documented on sexual violence in U.S. disaster shelters, thus this seems like it deserves more attention.

Our data bear one important limitation—the small sample size limits the study to being a case study. Moreover, we were limited by the amount and types of data in the database; in other words, we worked with the information that the West Fund decided to collect. Different people entered data, and some data were entered by the callers themselves into a web-based platform, both of which ultimately meant missing data on some variables. However, our objective was not statistical generalization or representativeness. Going forward, scholars should collaborate with other abortion fund organizations to document how weather-related and other disasters (including pandemics) shape abortion access and funds, with special attention to the callers’ reported travel constraints and experiences with violence. It would also be useful to explore disaster-related clinic closures. We are unaware of research that examines the disaster preparedness of abortion and reproductive health clinics. Much of the health infrastructure-related preparedness research is focused on hospital preparedness (Verheul & Dückers, 2020), but most abortions occur in free-standing clinics. Because communities need clinics to play the same substantive role post-disaster as pre-disaster, future research should study how organizational focus, professional experience, and larger regulatory policies enable and/or constrain clinic preparedness and response efforts.

Social scientists have long noted the effectiveness of sudden events such as natural hazards as triggers for faster and larger shifts in policy (Baumgartner & Jones, 2010, Yeo & Knox, 2019). These events disrupt power, offering windows of opportunity for politically disadvantaged interest groups to draw attention to previously ignored or overlooked problems (Birkland, 1998). In particular, we believe that our data reflect, in part, the effects of state and federal regressive abortion policies that require revision and/or revocation. We also recommend viewing and including abortion as basic healthcare, reflected in large part by full private and public insurance coverage.

While focus on state and federal policy reform is essential, abortion funds also deserve attention and funding as they are another avenue to combat economic and racial injustice through reproductive justice. An abortion clinic sample in a large Arizona city shows that nearly two-thirds of women reported having some assistance paying their expenses, from family (14%), a partner (46%), or a private abortion fund (4%) (Karasek et al., 2016). To us, this indicates that more patients and potential fundraisers/grantees could be aware of abortion funds and we hope that our research is one step in the direction of raising that awareness.

Although the people in our sample were facing multiple challenges, we argue that women’s vulnerabilities can be partially mitigated by expanding the disaster-response network. Disaster planners could collaborate with abortion clinics and funds in all stages of disaster planning. We also recommend more investment in domestic violence aid after disasters, including in disaster shelters themselves, which do not receive explicit focus in disaster studies on violence against women. Because one of the women in our sample stated that she was raped in a disaster shelter, we recommend that disaster planners pay closer attention to our shelters.

We also recommend the utilization of national-level abortion fund sources to assist city- or state-level abortion entities wherein national level entities should look out, plan ahead, and support/supplement smaller organizations who assist areas frequently impacted by disasters. In particular, because NNAF funding is largely devoted to second-trimester procedures, which are costlier than first-trimester procedures, shifting funding to local abortion funds directly after a disaster may ultimately be more cost-effective.

Conclusions

This qualitative case study offers a first analysis of the disasters and abortion juncture. As evident, this time-sensitive and common procedure remains critical care during and post-disaster. While weather-related disaster interrupts travel, childcare, employment, and clinic access, abortion need continues; in fact, it is a crucial piece to medical response. Fortunately, there are nonprofits that financially assist women across the country, providing an irreplaceable revenue to support women’s health outcomes, especially for vulnerable subpopulations. Despite these funds, however, the need for access to affordable abortion continues pre-, during, and post-disaster.