A group of angry men carrying anti-choice posters camped out near the abortion clinic. They shouted righteous denouncements of abortion, telling the women who visited the center they "didn't know what they were doing," and that the medical procedure was tantamount to murder. Elsa Vizcarra tried her best to tune them out as she walked into the clinic, but rosaries and pamphlets from religious crisis pregnancy centers were shoved upon her. And the more she ignored the protesters, the more belligerent they became. Even when a security guard sought to escort her safely to the clinic entrance from her car, he noted that the protesters became increasingly aggressive.

"It's even worse when they would try to obstruct the entrance or exit of the parking lot to the street," said Vizcarra. "They knock on your window and force you to stop your car so they can talk to you and try to convince you not to have an abortion."

However, thankfully for Vizcarra, the religious-right hostility had no bearing on her mission at the clinic. The University of Texas researcher wasn't there for a procedure but to document the experiences of abortion-seeking women in Texas. A string of GOP-authored anti-choice laws over the past few years has created a logistical maze for anyone to navigate in an already hostile and resource-depleted health care environment. Vizcarra, under the direction of UT's Texas Policy Evalua­tion Project (TxPEP) – a multiyear study examining the impact of the state's harsh reproductive rights regulations – visited a dozen abortion clinics across the state during 2018. While on the unconventional road trip, Vizcarra interviewed 603 women about the myriad barriers they faced obtaining abortion care in Texas. "I don't think a lot of people realize what it's like to actually visit an abortion clinic in Texas," she said. "It's not some dark, hidden place – it's a medical facility out in the open."

Vizcarra's survey – the first conducted by TxPEP following the U.S. Supreme Court ruling overturning 2013's landmark anti-choice House Bill 2, which nonetheless shuttered half of the abortion clinics in the state – is a reminder of the obstacles women still must jump through to get health care. Women have to contend with long treks to an abortion clinic, where they're required to make three appointments: One to receive a mandatory ultrasound of the fetus, followed by the procedure 24 hours later, then a third follow-up visit. A 2016 TxPEP study found that the average distance to the nearest provider in Texas increased fourfold after HB 2. The average one-way distance to the nearest abortion provider among women whose nearest clinic closed was 70 miles, compared to the previous 17 miles. Out-of-pocket costs and overnight stays also increased.

That means some women may forgo the trip altogether: A 2017 TxPEP study in the Journal of the American Medical Assoc­i­a­tion found that counties where the distance to the nearest facility increased 100 miles or more saw a 50% decline in abortions. A previous study additionally documented cases where the multiple burdens forced women to either obtain abortions later in pregnancy or, in a few instances, continue an unwanted pregnancy.

In cooperation with providers, Vizcarra spent whole days in clinic waiting rooms interviewing women, sometimes visiting a clinic more than once. She asked women about the timing of their pregnancies and decisions to seek care; their experiences finding a clinic; and whether they had visited an anti-choice crisis pregnancy center first. She asked about access to medical abortion, birth control use, insurance and out-of-pocket costs related to their procedure, and about women's knowledge and perceptions of abortion regulations in Tex­as. "Women expressed many difficult points along the way, including accessing transportation, getting time off work, finding child care, and traveling very far," she said.

For instance, a working mother who lived in rural Texas, around 70 miles from the nearest abortion clinic, was forced to get a payday loan to cover her procedure. She didn't have access to a car and had to rely on someone to drive her to the clinic for her sonogram, then come back again after waiting the state-mandated 24 hours before getting the procedure. She couldn't afford to make the third follow-up visit. Another woman had to make the lengthy round-trip to get an ultrasound twice, as she couldn't get off work to visit the clinic with the same physician in time.

Many voiced surprise and confusion over state regulations: One working professional Vizcarra interviewed didn't realize that legislators barred private insurance from covering abortion care in 2017, and that she'd have to pay out of pocket for the procedure. That patient was also delayed in securing her first appointment for more than two weeks because the clinic was so backed up.

Atop the cost and travel barriers, women must face confrontational activists camped out near abortion centers who seek to shame them – a daily presence at most of the clinics Vizcarra visited. Her experience reflects a national trend. In 2018, the number of people attempting to intimidate patients and disrupt services at abortion clinics continued to increase at an "alarming rate," found the National Abortion Federation in its latest report on violence at abortion clinics. Since 2015, the number of anti-abortion protesters reported at clinics jumped more than fourfold and acts of obstruction, such as trespassing, skyrocketed by more than 1,000%. Harassment and vandalism also rose.

"In addition the external stressors, like having to come back due to mandatory waiting periods, women have to deal with the stigma caused by protesters," said Viz­carra. "It was the first thing you encountered when you came to a clinic, and they were so loud, so vocal. It made the whole experience even more difficult. But I would say that despite all of those barriers, [the] women were so strong in the face of adversity."

TxPEP is in the process of analyzing all of Vizcarra's work and plans to release the study findings this fall.