In a patchy brown grass lot next to the Whole Woman's Health clinic in McAllen, Texas, large signs featuring light-skinned, blue-eyed babies implore women in incoming cars to turn around. "Please Don't Believe the Lies," one reads. "Abortion Kills Your Baby." Another: "Abortion Is Always the Wrong Choice." Finally: "Abortion The Ultimate Child Abuse."

These days, the signs aren't speaking to anyone in particular: The McAllen clinic shut its doors in March, one of many victims of Texas's strict anti-abortion laws.

Even before the clinic closed, it was forced by law to stop performing abortions. It was, however, providing pregnancy tests, sonograms, counseling, and follow-up care for women who had terminated pregnancies elsewhere. As choices for local women waned, Andrea Ferrigno, who ran the McAllen clinic and now works as the vice president of Whole Woman's Health in Austin, says she and her colleagues reached out to hospitals in the Rio Grande Valley to help educate staff on post-abortion care.

"The director of one ER said to us, 'Oh, I was wondering what was going on, since I've been seeing a lot of miscarriages lately,'" Ferrigno said. "We tilted our heads and said, 'It's not miscarriages. It's underground use of Cytotec.'"

Anti-abortion signs still loom over the lot next to the now-closed Whole Woman's Health clinic in McAllen. It was the last abortion clinic in the Rio Grande Valley. Kathleen Kamphausen

Cytotec, an ulcer medication commonly used off-label in Latin America to induce abortions, is the brand name for misoprostol, a drug taken in combination with mifepristone in the safe, legal "abortion pill" procedures across the U.S. known as medical abortions. Cytotec causes uterine contractions, and although it's less effective on its own, it still works 90 percent of the time if taken within the first 12 weeks of pregnancy — after that, the chances of complications rise. Some Valley women get Cytotec online. Others cross the border into Mexico, where it's rumored to be easier to come by. Still others buy it at the local pulgas, or flea markets, where quietly asking for "a pill to make my period come down" may result in a man pressing a capsule into your palm, if the police haven't raided the place.

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What happened to McAllen's clinic is just one piece of a statewide trend. Texas today is something of a hub for extreme anti-abortion laws, with a maze of inventive barriers to abortion and even contraception access popping up at nearly every turn. Come September, only six abortion clinics will operate in the state, down from today's 21 clinics, which is already down from 2011's 44. Those six clinics, all in major cities, will serve 5.4 million women of reproductive age, 75,000 of whom terminate pregnancies every year. Since the McAllen closure, there have been no abortion clinics left in Texas's vast Rio Grande Valley, and soon there will be no abortion clinics in the entire chunk of the state west of San Antonio, including the panhandle.

The Road to Access

The drive from Brownsville, Texas, to San Antonio, where the nearest clinic is located, is four hours on a flat stretch of highway across the Valley, sun beating down, bugs splattering across the windshield. The Texas sky is very blue, crops line up in neat rows, and as dusk nears, the moon and the sun coexist in the sky for an improbably long time. It's down this long road that women in Texas's Rio Grande Valley have to go if they want to legally terminate a pregnancy.

Women in the Rio Grande Valley have to drive hundreds of miles to the nearest abortion clinic. Kathleen Kamphausen

The drive is particularly difficult when it's punctuated by the anxiety of preparing to undergo (or just having undergone) a medical procedure. And it's not a cheap one: There's no public transportation linking the Valley to San Antonio, so women need access to a car — something many Valley residents don't have — and money for gas, which can cost more than what a Valley woman makes in a whole day. Driving nearly 300 miles and then having an ultrasound or an abortion means a woman has to take the whole day off work, and women in the Valley, who are likely to work in textile manufacturing or in the fields or as cleaning staff, often don't get paid if they don't work. According to abortion providers' surveys of patients, some 70 percent of Valley women who terminate pregnancies already have children, so driving to San Antonio means paying for childcare too. And since Texas law requires two in-person clinic visits, one for counseling and an ultrasound, and one for the abortion a full 24 hours later, having an abortion means doing all of this twice, or paying to stay overnight in a hotel.

Not so long ago, a Brownsville resident could drive to the nearest clinic in about an hour. Brownsville sits near the southeastern tip of the Valley, a stretch of land bordering the Rio Grande, which separates the United States from Mexico. As you drive northwest, Brownsville's red-brick Americana, with its old-timey movie theater and middle-school cheerleading squad photos taped in windows of local businesses, disappears in the rearview mirror as town gives way to highways crisscrossing the Texas farmland where Valley residents and migrant workers bring watermelon and onions to much of the U.S. When shiny car lots and Asian-fusion restaurants dot the landscape, you're in McAllen.

Homes in Brownsville. The city is one of the poorest in the United States. Kathleen Kamphausen

Many Valley residents live in the outskirts of both cities and in the vast rural land in between and northeast of them, some in small houses and some in trailers; hundreds of thousands of people in the Valley live in unincorporated colonias, often with limited access to clean water and without sewage systems. Brownsville and McAllen are the Valley's two largest metropolitan areas and, despite robust cross-border commerce and a smattering of bustling local businesses, two of the poorest cities in America. More than a third of households in the Valley live below the poverty line, and average incomes are just above $30,000 a year.

Clinics have closed in the Valley and across the state because of H.B. 2, the 2013 Texas law that Wendy Davis spent 11 hours filibustering, but that eventually passed in a special session called by Gov. Rick Perry. While abortion has long been controversial in Texas, H.B. 2 was a catastrophic blow to access. The bill has four parts, and most of its requirements went into effect in November, including one stipulating that most abortions after the 20th week of pregnancy are illegal and another requiring that women having medical abortions make four separate in-person visits to a medical facility. Starting September 1, all abortions must be performed in ambulatory surgical centers instead of standard abortion clinics.

These regulations are add-ons to Texas's existing laws restricting abortion access. Even before H.B. 2, the state barred Medicaid funding for low-income women seeking to terminate pregnancies; required counseling, an ultrasound, and a 24-hour waiting period; and mandated that teenagers get their parents' written permission to terminate.

"Every time a law passes there's a group of women who can still make it over that barrier," Whole Woman's Heath CEO Amy Hagstrom Miller said. "But with each law, that group gets smaller and smaller. With each law, there's a group of women who get left behind."

H.B. 2 also compels abortion providers to have admitting privileges at local hospitals, which are difficult to get: Abortion remains highly stigmatized, so many hospitals simply won't accept abortion providers or even provide an application; some hospitals require a current physician to co-sign the application, something many doctors are afraid to do lest they become targets for anti-abortion harassment and violence; and hospitals typically require a physician to admit a minimum number of patients every year, but abortion is so safe that complications requiring hospitalization are rare. Many clinics in Texas, including the one in McAllen, have not been able to meet the admitting privileges requirement.

Though pro-choice groups challenged the provision and won in the district court in Texas, the Fifth Circuit Court of Appeals panel upheld it in March because, the court wrote, getting to an abortion clinic in Corpus Christi from the Valley "takes less than three hours on Texas highways."

On a June day in her office in Austin, Hagstrom Miller, who still operates clinics in San Antonio and Austin, gestures to a poster-size map of Texas, with sticky notes marking surviving clinics. She pulls one off and crumples it up — earlier that week, the clinic in Corpus Christi shut down.

Amy Hagstom Miller keeps a map of the remaining Texas clinics in her office. A clinic in Corpus Christi closed in June and more are set to shutter by the fall. Kathleen Kamphausen

"With the Corpus Christi office now closed, San Antonio is it for this huge swath," Hagstrom Miller said, waving her palm across the peninsula-shaped bottom third of the state. "I look at it all the time and I think, What are women going to do?"

Turning to Unsafe Methods

An hour onto the road from Brownsville to San Antonio, you hit Sarita, Texas, a town unremarkable from the highway but for its U.S. Customs and Border Protection checkpoint. Even though you haven't left Texas, let alone the United States, every car has to stop and answer an agent's question: "Are you a U.S. citizen?"

If the answer is yes, you can drive through. But many Mexican nationals are in the Valley legally on a border-crossing visa, which allows visitors to enter the U.S. for 30 days but only travel within a 25-mile radius, so they can't cross the checkpoint. And if you're undocumented, as are a quarter of people in the Valley, you're not going to risk getting caught by immigration officials.

All of the highways out of the Valley have checkpoints like the one in Sarita. When the checkpoint means they can't drive to San Antonio, some women go through with pregnancies they don't want. Others turn to Cytotec. Still others find out about unlicensed providers who perform cheap abortions out of their homes.

"There are clinics here that provide abortions, but illegally," Lily, a 19-year-old beauty school student in Brownsville, said. "It's a secret. You have to know it by your friends and friends of friends. They do surgeries. And you can get pills to take at home. I've heard about if you drink a really, really hot beer, you get an abortion. It works. Or you can buy herbs on the Internet — you can find everything there."

Along the Texas-Mexico border, 12 percent of women report taking something to try and induce an abortion before coming to a clinic (statewide, the number is 7 percent). And that number counts only women who self-reported and women who eventually made it to an abortion clinic — the actual number of women who attempt to self-abort is surely much higher.

"It's different from pre-Roe," Hagstrom Miller said. "At least we have some medications that are proven to be safer than coat hangers and douching with bleach, although we're seeing that as well. We're seeing more women who say, 'I asked my husband or boyfriend to beat me in the stomach,' or, 'I threw myself down the stairs.' There are a lot of teas that are known abortifacients, especially in the Latina community. Women talk to each other."

Many Valley women get abortion-inducing drugs from local flea markets. Kathleen Kamphausen

Despite the clinic closure, Whole Woman's Health still answers the McAllen phone number to tell patients their options, even as those options become fewer and fewer, and women more and more desperate.

"I remember this woman called and I explained to her we weren't in McAllen anymore, but she could go to San Antonio," former clinic director Ferrigno said. "She became really frantic and said, 'I can't do that; I can't cross the checkpoint.' And she said, 'Tell me what I can do with what I have at home. I'll go through my kitchen cabinets and tell you what I have.'"

Ferrigno told the woman to talk to a doctor in town and warned her of the dangers of trying to self-induce. But months later, she still worries.

"All I could do was advise her not to do anything unsafe," Ferrigno said. "But if she couldn't get what she needed from a medical provider, I don't know what she did."

A Pro-Life Sandwich

Instead of trying to outlaw abortion wholesale, in recent years, anti-abortion groups have embraced a strategy of chipping away at abortion rights through a series of smaller, targeted laws, making it increasingly burdensome to get the procedure. When the laws are challenged, proponents argue that the burden is not so heavy that it's impossible to shoulder, and they frame the regulations as promoting women's health.

But Republican-dominated legislatures aren't developing these laws with women's health care providers — they're working with anti-abortion groups write them.

"Texas Alliance for Life is very involved in crafting the legislation that the legislature considers," said Joe Pojman, the anti-abortion group's executive director. When it comes to several of Texas's anti-abortion laws, "what passed is almost verbatim what we drafted."

That includes sections of H.B. 2.

"Lt. Gov. Dewhurst put the major legislative leaders and the major pro-life groups in a room and asked us what the bill should contain," Pojman said. "He took the favorite components of the major groups and the major legislators and put them together. I compare it to a sandwich of cold cuts: Each of us had a favorite slice, and each of us had incentive to support the bill."

Joe Pojman of Texas Alliance for Life says his group is 'very involved in crafting the legislation' that impacts abortion rights in the state. Jill Filipovic

H.B. 2 isn't the only law penned by Republicans in collaboration with anti-abortion activists. In 2011, after a national campaign by Americans United for Life (AUL) and other anti-abortion groups to defund Planned Parenthood, Texas cut $73 million in family planning funds so they could prevent taxpayer dollars from going to the organization — despite the fact that abortion accounts for just 3 percent of Planned Parenthood's services, and the group was one of the largest providers of reproductive health care to low-income women in the state. To legally strip money from Planned Parenthood and other family planning providers, the state also rejected tens of millions of federal Medicaid dollars and distributed the remaining state funds away from family planning clinics.

As a result, almost a third of family planning clinics in the Valley closed, and others could only stay open by raising fees. The cost of contraception and annual exams increased more than threefold, and the number of women receiving services from state-funded family planning services fell by 72 percent. The outcome was that Texas women had a much more difficult time preventing unwanted pregnancies: According to a 2012 survey of 300 women seeking abortions in the state, nearly half of them said they were unable to access the contraceptive method they wanted to use. Over the next two years, low-income Texas women are projected to have nearly 24,000 more babies than they would have without the cuts, costing taxpayers an additional $273 million.

A year after the 2011 cuts, AUL applauded Texas's "aggressive legislation" against abortion. They then set out four pieces of "top priority" laws for politicians in the state to work on.

A year later, three of the four were components of H.B. 2.

The Regulations' Cold, Hard Reality

On a large lot housing several nondescript medical practices in identical one-story brick buildings, two Whole Woman facilities sit across the parking lot from each other: Whole Woman's Health, an abortion clinic serving women between three and 16 weeks of pregnancy (nearly 90 percent of abortions are performed in the first 12 weeks), and Whole Woman's Surgical Center, which provides abortions for women up to 20 weeks pregnant.

The Whole Woman's Health clinic that provides earlier abortions is thoughtfully cozy, with a purple-hued interior and quotes from famous women — Maya Angelou, Eleanor Roosevelt, Audre Lorde — painted across the walls. When a woman comes to the clinic, she is legally required to meet with the doctor who will perform the procedure; that happens in a comfortable, warmly lit room. She has an ultrasound that same day, and, again as legally required, the doctor describes the fetus's development, offers to show her the ultrasound, and lets her hear the fetal heartbeat. Then she's told to come back the next day for the procedure, which is done in less than 10 minutes, in a room that feels like a gynecologist's office. When the abortion is over, nurses escort the woman to a recovery room where she sits in an over-stuffed armchair, sips hot tea, and snacks on crackers until she feels well enough to go home. When an early-term abortion is done by a safe, legal provider, the chance of serious complications is less than one-half of one percent.

The Austin Whole Woman's Health Clinic feels like a comfortable gynecologist's office. Kathleen Kamphausen

Because it doesn't meet the final requirement of H.B. 2, this clinic will close by September. All of the patients who would have gone to it will have to go to the surgical facility across the lot, whose current patients include many women whose wanted pregnancies went tragically wrong (many serious complications aren't detectable until several months into the pregnancy). Whole Woman's Surgical Center meets Texas's requirements for ambulatory surgical facilities, which are complex and highly detailed: Everything from a room's temperature to the light bulbs to the paint on the walls is regulated, and so operating an ambulatory surgical center can cost $40,000 or more a month. Patients wear hospital gowns, have the procedure performed on an operating table, and recover lying down on a gurney. There's an ambulance bay outside. It feels like a mini hospital — cold, antiseptic, serious.

Fatimah Gifford, the communications director of Whole Woman's Health, says lost in the policy discussion of H.B. 2 are the feelings of fear a hospital environment stokes. She said women ask her, "Why do I feel like I'm going into a hospital? I thought you said this was safe?"

Whole Woman's Surgical in San Antonio is an ambulatory surgical center. All procedures here are performed in operating rooms — even medical terminations with the 'abortion pill.' Kathleen Kamphausen

"We had this wonderful environment where we created an oasis for women to have a safe space to examine a big life decision," Hagstrom Miller said. "They could count on high-trained professionals to take care of them medically and were also welcome to bring their whole selves — the spiritual conflicts some women feel, the ethical and moral issues. That is one thing this law has taken away: that environment of dignity and respect."

Ambulatory surgical centers are made for minor surgeries that require incisions. Early abortion is incision-free and does not require general anesthesia; medical "abortion pill" procedures are even less invasive. But once H.B. 2 is in full effect, even medical abortions will have to be performed at surgical centers.

Medical abortions are a two-pill regimen of mifepristone and misoprostol: In most states, the first pill is taken at the clinic, and it stops the embryo from growing; the second one, taken at home one to three days later, empties the uterus. In Texas, women have to take both pills directly from a physician, which means a woman seeking a medical abortion makes four trips to a clinic: one for the ultrasound and counseling, one for each of the pills, and one for the follow-up appointment. After September, she will be legally required to take both pills while sitting on an operating table in a sterile surgical room.

There's no medically indicated reason why women should take either pill in a surgical facility, but there are very good reasons to take the second one at home: Cramping and bleeding can begin as soon as 15 minutes after ingesting it. Texas law means a woman might start bleeding or cramping on her way home. As Texas women have to drive farther and farther, that's a bigger and bigger problem.

Looking Down the Road

Whole Woman's Health has been looking to rent another facility so they can serve more women, but no one is willing to give them a lease. They've offered to share space with existing ambulatory surgical centers that perform procedures like knee surgeries, saying they'll contribute to the rent and operate after hours or on Sundays. They've made more than 200 inquiries, but no one is willing to work with them. Building a new facility would cost several million dollars.

In the meantime, abortion providers and pro-choice leaders try to cobble together resources to help women like those in the Valley. Activists can't make the drive any shorter, but groups including the Lilith Fund and the Stigma Relief Fund help low-income women pay for the procedure, and networks of volunteers offer couches to sleep on for women coming from far away. The consensus, though, is that these stopgap efforts are valiant but unsustainable.

"We have come up with this Band-Aid system to help women to come up with money to have an abortion and to sleep on someone's floor or sleep in a parking lot," Hagstrom Miller said. "That's not heroic — that's a tragedy. And the state is the villain here."

In September there will be just six abortion clinics left in Texas. None of them are west of San Antonio or in the state's southernmost Rio Grande Valley. Tara Rice

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Photo credit: Kathleen Kamphausen for Cosmopolitan.com

Jill Filipovic senior political writer Jill Filipovic is a contributing writer for cosmopolitan.com.

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