Al Letson:From the Center for Investigative Reporting and PRX, this is Reveal. I’m Al Letson. This month marks a year since Roe v. Wade was overturned, and since then we’ve had a team of reporters, producers, and editors covering how the ruling is impacting people across the country. And it isn’t just people wanting to have abortions. It’s also about people who are trying to have kids. This hour, we investigate a budding healthcare crisis in this new post Roe reality. Nadia Hamdan is a part of the team covering reproductive health, and she’s going to be your host for today’s episode. Nadia takes her from here. Nadia Hamdan:Thanks Al. So we start in Texas, my home state, where the most recent fight over abortion rights has been playing out the longest. It all starts there in September of 2021, nine months before the Supreme Court’s bombshell decision. Speaker 3:One of the strictest abortion laws in the country takes effect in Texas today. It bans the procedure after six weeks of pregnancy and that’s before many women even know they’re pregnant. Nadia Hamdan:The new law says a doctor is not allowed to perform an abortion if the fetus has any sort of cardiac activity. Speaker 3:The law also allows private citizens to bring civil suits against anyone who assists a pregnant person seeking an abortion. Nadia Hamdan:Doctors, nurses, and others are worried. Then Roe v Wade gets overturned and things get even more complicated, because another law goes into effect. And now it’s not just civil lawsuits, it’s also the fear of criminal prosecution. Speaker 4:Performing any abortion, except those to save the life of a woman, is a first degree felony. The penalty is five years to life in prison and a $100,000 fine. Nadia Hamdan:The stakes are just so much higher for doctors and nurses. What if something they do is considered crossing a line? One labor and delivery nurse in San Antonio wanted people to understand what she’s dealing with. So she goes on TikTok. Leah Wilson:Nurse Leah here, and I feel compelled to discuss what life has been like for us with y’all, since the repeal of Roe v. Wade, also known as the Dobbs decision. Nadia Hamdan:Leah starts to list scenarios where an abortion would be medically necessary for the health of the patient. These are standard procedures that they now worry could get them arrested. Leah Wilson:If Mom is miscarrying, but hasn’t completely miscarried, but the baby still has a heartbeat, and we deliver that baby to stop her bleeding, that’s an abortion. Nadia Hamdan:Her post goes viral and has gotten more than 200,000 views. Leah Wilson:I cannot stress enough. Abortion is not what people think it is. Nadia Hamdan:Doctors and nurses like Leah say they’re being put in impossible situations that are testing their medical ethics. Sophie Novak recently wrote about this. She’s a freelance reporter based in Texas who covers reproductive health. Her latest piece for Slate talks about the real world impact of these laws on healthcare providers and how people like Leah are questioning whether they can stay in Texas. Hey, Sophie. Sophie Novak:Hey, Nadia. Nadia Hamdan:Sophie, you actually tracked Leah down. What can you tell us about her? Sophie Novak:So her name is Leah Wilson. She started as a labor and delivery nurse at a hospital in San Antonio not too long before Texas’ six-week ban went into effect. And she actually initially got into nursing because she was inspired by the way that nurses helped her through a complicated birth of one of her kids. She tells me that just a few weeks after the full abortion ban went into effect here, under the state’s trigger law, she had a particularly difficult case. It was a patient who was only 19 weeks pregnant when her water broke. Leah Wilson:Typically, you would say, “Well, this is not a viable pregnancy. There is a 0% chance that a 19 week fetus who has already had their water broken and already has an infection is going to survive.” Sophie Novak:That patient developed chorioamnioitis, which is an infection in the amniotic fluid and the placenta. Leah Wilson:The normal standard of care anywhere else would’ve been, “We’re going to induce.” Sophie Novak:Normally they would induce labor and end the pregnancy in order to get rid of the infection and prevent it from becoming life-threatening. But Leah says that that changed at her hospital under the new law. Leah Wilson:And when this poor patient, when we would walk in her room, it was you could smell that infection. And I remember going to the on-call physician and saying, listen, “Her white blood cells are elevated. She smells like chorio.” And he goes, “That’s not sufficient reason. That’s not a sufficient reason.” Sophie Novak:So instead Leah says that that doctor told her that they had to wait until the fetal heartbeat stopped completely or until the infection spread through the patient’s body. Nadia Hamdan:Wow. I mean, in my experience, doctors never want to wait for an infection to spread. Sophie Novak:And Leah says that this patient sat with the infection for three days until the fetal heartbeat stopped. Leah Wilson:There’s so much of a moral conflict knowing what the right thing to do is for a patient, trying to advocate for it, knowing that the physician’s hands are tied, and just prolonging suffering. Sophie Novak:Soon after that, Leah left her job at the hospital. Nadia Hamdan:So Leah is saying that while these abortion laws say there are exceptions for medical emergencies and life or death situations, the problem is they don’t really define what counts as an emergency. Is that right? Sophie Novak:Right. So for example, is it when a patient’s water breaks before the fetus can survive on its own? Or is it when they get an infection as a result? Or is it when that infection becomes sepsis? Basically, how sick do they have to be for their life to be considered at risk? And some hospitals are requiring doctors to check with attorneys about intervening in every case. So the danger with this kind of hesitation, of course, is that these complications can really quickly become life-threatening emergencies. Nadia Hamdan:Yeah, I mean, I can see why Leah decided to leave. I mean, Sophie, you’ve spoken to a bunch of doctors and nurses for this story. How many more are thinking of leaving? Sophie Novak:Yeah, so I spoke with nearly two dozen providers from all around Texas about this, and some of them had already left the state or their practices as a result of these laws. Almost all the folks that I spoke with have wrestled with this question of how long they’re able to continue doing their jobs in Texas under these restrictions, from OBGYNs- Speaker 8:There’s probably not a day that goes that goes by where I don’t think, “Huh, is this where I really want to be.” Sophie Novak:-to family medicine doctors- Speaker 9:It was very unclear what is aiding and abetting an abortion. I don’t know whether I’m committing a crime or not. Sophie Novak:-to maternal fetal medicine specialists. Dr. John Visint…:I think it’s a tragic and horrible situation to be in. Sophie Novak:That last clip is Dr. John Visintine who works in the Rio Grande Valley on the Texas-Mexico border. He cares for people with high risk pregnancies. So for example, if they have a medical condition that makes their pregnancy really dangerous or if their fetus has an anomaly that means it’s not likely to survive. Normally in those kinds of cases before the abortion ban, he would talk through with a patient the option of ending their pregnancy. Dr. John Visint…:And when you can no longer discuss the option of termination with a mother, based on how I’ve been counseled by our attorneys, I’m not even supposed to discuss the option of going out of state. To withhold that information, it feels unethical. Sophie Novak:He says these kinds of situations are happening several times a week now, and as a result, he regularly thinks about leaving. Dr. John Visint…:I don’t think the state legislators understand the position they put their doctors in, and I think the effects of what they’ve done, I think, will come to light and I’m afraid it’s going to manifest in maternal mortality rates. Nadia Hamdan:So he’s essentially saying that more women may die because of these laws. Sophie Novak:Right. And that’s something that a lot of people have been warning about these kinds of abortion bans for a while now. And Texas already has a high maternal mortality rate. Nadia Hamdan:I mean, Sophie, are we seeing any sense of urgency from lawmakers to address these very real concerns? Sophie Novak:In short, no. Governor Greg Abbott did do a local TV interview while he was campaigning for reelection where he acknowledges problems with some of the language around medical exceptions. Greg Abbott:There seems to be some confusion about the way that the life of the mother is to be protected. Let me just give you a couple of quick examples. Sophie Novak:So he mentions ectopic pregnancies and the apprehension by doctors when dealing with miscarriages. Greg Abbott:I want to see legislation come out that will both do more as well as to clarify the ways in which we are protecting the life of the mother. Sophie Novak:So Democrats put forward bills to widen exceptions for medical emergencies and to create exceptions for rape and incest or when the fetus has a serious condition and won’t survive. But only one narrowly written bill that I’m aware of has passed. The Governor hasn’t signed it yet. It would give providers some legal protection in case like Leah’s patient when the water breaks too early or when the pregnancy is ectopic. Nadia Hamdan:Okay. But there is a lawsuit that’s trying to go further than this. Sophie Novak:Yeah, it was filed in March, and it asks the courts to clarify medical exceptions and affirm that doctors have discretion to intervene so that patients don’t continue to be put at risk. At first, the plaintiffs were two doctors and five women, and since then, eight more women have joined the lawsuit. They all talk about having harrowing experiences while dealing with complications during their pregnancies. One of them actually went to Washington DC and she told her story before the Senate Judiciary Committee. Amanda Zaraski:My name is Amanda Zaraski and I’m here to tell you a little bit about my experience with the Texas abortion bans. Sophie Novak:Her water broke at just 18 weeks of pregnancy, but her hospital said that there was nothing they could do under the state’s abortion laws. Amanda Zaraski:People have asked why we didn’t travel to a state where the laws aren’t so restrictive, but we live in the middle of Texas and the nearest sanctuary state is at least an eight-hour drive. Developing sepsis, a condition that can kill in under an hour, in a car in the middle of the West Texas desert or on an airplane is a death sentence. Sophie Novak:Three days later, she went into septic shock, and only then did doctors give her an emergency abortion. She ended up fighting for her life in the ICU. Amanda Zaraski:The preventable harm inflicted on me has already made it harder for me to get pregnant again. The barbaric restrictions that are being passed across the country are having real life implications on real people. I may have been one of the first who was affected by the overturning of Roe in Texas, but I’m certainly not the last. Nadia Hamdan:Sophie, when I first heard Amanda’s story, I couldn’t stop thinking about how she said people were asking her why she didn’t just leave the state if she had the means to do so. Imagine asking someone whose appendix just ruptured to get on a plane or sit in a car for eight hours. I mean, it just seems absurd to ask a pregnant woman in an emergency to travel anywhere. Sophie Novak:Yeah, and I mean, I’ve been covering healthcare in Texas for years now, and I’ve long thought about, and frankly been frustrated by, the way that reproductive healthcare often gets siloed from other kinds of medical care. And I think Amanda’s story and others that we’re seeing in the wake of the Dobbs decision underscore the real danger in that. Nadia Hamdan:Now, Sophie, as you just said, you’re a reporter and I know reporters don’t usually like making the story about themselves, but I’d like to get a little personal here for a minute because while we were trying to schedule this interview with you, you actually went into labor yourself and had a baby. Congratulations, again. Sophie Novak:Thanks so much. Nadia Hamdan:I guess I want to know what it was like to do this reporting at the same time you’re dealing with your own pregnancy. Sophie Novak:Yeah, I mean, being in a state with one of these bans really changed everything about how I thought about my own pregnancy. And doing this reporting reinforced what I already knew, that having a child here is risky. So I happened to be about 19 weeks pregnant while I was talking with Leah, who’s the nurse in San Antonio, about her patient’s miscarriage at 19 weeks. And I remember reading about Amanda’s experience here in Austin, which is where I live, and the scenarios that she talks about are ones that I actually talked about with my husband as well. So if something like that happened with me, would we wait for care in Texas or would we go somewhere else? Nadia Hamdan:So at the same time, you’re picking paint colors for the baby’s room you’re also picking which state to go to if something goes wrong. Sophie Novak:Yeah, like would we try to get on a plane to, say, Colorado, like one of the other plaintiffs in the lawsuit did. She ended up paying extra for a seat near the bathroom in case she went into labor or hemorrhaged mid-flight. Nadia Hamdan:Wow. Sophie Novak:And I mean, I’m fortunate enough to have options, as awful as they are. I’m lucky to be healthy and to have a healthy newborn at home. But ultimately these laws are making pregnancy much more dangerous for everyone, both in individual cases where needed medical care is delayed and also more broadly, as we see doctors and nurses start to quit in a state that already has far too few of them. And that’s something that people like Dr. Visintine are weighing constantly as they’re thinking about whether to leave their practice in Texas. Dr. John Visint…:And then if you leave, then there’s so many women that need care in this area. Do we just abandon the women of South Texas that just have no care at all? I think it’s a real dilemma. Sophie Novak:That tug of war between trying to comply with the law and this ethical obligation to their patients and community is echoed by so many of the medical professionals that I spoke to for this story, and it really underscores just how precarious this moment is. Nadia Hamdan:Sophie, thanks so much for your reporting and for bringing us this story. Sophie Novak:Thank you. Nadia Hamdan:Sophie Novak is a freelance reporter covering healthcare in Texas. You can find a link to her Slate article on our website, revealnews.org. As doctors and nurses face ethical dilemmas, the anti-abortion movement is pushing their own brand of care. Angela Curatalo:There’s people out there who say we lie, we coerce people. We don’t do any of that. Nadia Hamdan:The rise of crisis pregnancy centers. That’s coming up, on Reveal. From the Center for Investigative Reporting and PRX, this is Reveal. I’m Nadia Hamdan, sitting in this week for Al Letson. We just heard how strict abortion bans in Texas are disrupting the medical system and causing some patients and doctors to want to flee. Florida is one of the latest states to restrict abortion access. In April, state lawmakers there banned most abortions after six weeks. That law has been all over the news, and is currently being held up in the courts. But there is a part of that law that hasn’t gotten much attention, $25 million in funding for these places called crisis pregnancy centers. These centers, which are often called CPCs, say they exist to offer resources to pregnant women, things like free pregnancy tests and sonograms, but they’re often religiously motivated, and they have one mission, to stop people from ending their pregnancies. And Florida just gave these centers five times more funding than the year before. There are already more than 2,500 CPCs across the country. That’s an average of three for every one abortion provider. Reveal reporter Laura Morel covers reproductive health. She lives in Florida and spent the past year looking closely at crisis pregnancy centers, not just in her home state but across the country. Her investigation found that while more taxpayer dollars are funding CPCs, most don’t really have anyone dictating to them what they can and can’t do. And that is putting women’s health at risk. Hey, Laura. Laura Morel:Hey Nadia. Nadia Hamdan:All right, so you want to introduce us to a woman from Jacksonville, Florida who says she was tricked by one of these pregnancy centers. And we’re calling her Beth, but that’s not her real name. Laura Morel:Right. Beth is a pseudonym that we’re using to protect her identity. It’s also because everything that happened to her, everything I’m about to tell you, really shook her trust in people. Beth was even hesitant to meet with me at first, so I offered to meet with her in a super public place, the patio of a crowded restaurant, which is why it sounds pretty noisy here. Okay, so it’s recording. I can pause it at any time. Beth:Okay. Laura Morel:So her story starts in the spring of 2018 when Beth found out that she was pregnant. She knew that she didn’t want to continue the pregnancy, so she made an appointment with the local abortion clinic. And when she arrived for the appointment, she saw two buildings with similar logos and names. One was called Florida Women’s Center and the other one was Women’s Help Center. Nadia Hamdan:Are those not the same thing? Laura Morel:Well, Beth thought they were, because not only do they sound the same, the font on the building sign was identical, like the exact same curly cursive for the word women’s. She ended up entering the help center and walked up to the front desk. She filled out a form with her medical information and was escorted into a room where she met a woman named Patricia Henderson. Beth:This woman said she was a doctor, like she said that I had the medical appointment with her and she took me back into the room and she asked me what my pain scale was on one to 10. She asked me if I had spotting. She asked me like all these- Laura Morel:And when Beth told her that she had some pain, which is pretty normal in the first trimester, Patricia kind of sat back and got really serious, and told Beth that she couldn’t have the abortion that day. Beth:“You’re not giving me the pill today?” And then she’s like, “Yeah, we’re not doing the abortion today.” She’s like, “But let’s still do the ultrasound and see where you’re at.” And she comes and she takes me down the hallway and we go into another room, the ultrasound room, and she gives me a gown to change into. Laura Morel:And everything looks like medical? Beth:Super medical. Laura Morel:She didn’t have any reason to believe she wasn’t in a real clinic. Nadia Hamdan:Right. So what happens next? Laura Morel:By this point, Beth’s instincts are telling her that something is off and she starts to become suspicious. Beth:“Are you the people I made the appointment with?” And she’s like, “Well, we don’t do those here.” Nadia Hamdan:So you’re telling me after all of this, Beth says that’s when Patricia told her they don’t do abortions. Laura Morel:Right. And Beth felt really duped. Beth:I was like, “But you told me in the beginning that you did. Like, just went through all of this and told me that you did.” I was like, “You made me miss my appointment.” Nadia Hamdan:Oh, wow. So Beth actually missed her appointment at the abortion clinic. Laura Morel:Yeah. But once she kind of realizes what’s happening, she gets up and leaves and rushes over to the real clinic. Beth:I was like sobbing. I was so upset. And they asked what happened and they explained like, “I went next door.” Laura Morel:So posting up right next door to an abortion provider using similar sounding names, these are super common tactics used by pregnancy centers across the country. I mean in Florida alone, I found that more than a quarter of abortion clinics have a center less than a mile away. Nadia Hamdan:And clearly this is a tactic that tricked Beth into coming in. So, Laura, what ended up happening with Beth, was she able to get her abortion? Laura Morel:She was. The doctor at Florida Women’s Center was able to see her and give her the abortion pill. And while she was there, the clinic staff told her that she wasn’t the only one this had happened to, which I was able to confirm Nadia Hamdan:How? Laura Morel:Well none of this had been made public. A source told me that the Florida Department of Health had gotten involved. So I filed a records request with them and a few weeks later they sent me this complaint. And it turns out that investigators with the Health Department found that Patricia wasn’t a doctor. She was a radiology technician whose license expired. They also found seven other women who said they were deceived by Patricia. Nadia Hamdan:And what did those women say exactly? Laura Morel:Well, a few told investigators that Patricia stood outside in the parking lot wearing a lab coat and told them their abortion appointments were in her building. And once they were inside, the women said she’d perform an ultrasound on them and give them wildly inaccurate information about their pregnancies. Investigators wrote that she told one woman she wasn’t pregnant and just had a stomach virus, but that wasn’t true. They also wrote that Patricia told another woman not to bother getting an abortion because her nine-week old embryo wasn’t forming properly and said she would have a miscarriage in a week. That also wasn’t true. Nadia Hamdan:I can’t imagine a doctor predicting the date of my miscarriage. Laura Morel:Right. But a common tactic for pregnancy centers is to delay. So if you make someone believe that they don’t need an abortion or that they don’t need one right away, they’re more likely to miss their chance, especially in states with bans and restrictions in place. Nadia Hamdan:Laura, I’m listening to you and I just keep thinking, I mean these are pretty serious complaints. Laura Morel:And that’s not even the worst thing I read. Investigators say Patricia told a woman she had an ectopic pregnancy. That it was normal. She should relax at the beach and come back later for a follow-up. Luckily, Patricia was wrong, because if ectopic pregnancies aren’t treated immediately, they can lead to massive hemorrhaging and sometimes even the woman’s death. Nadia Hamdan:Laura, do Patricia or the clinic have anything to say about this? Laura Morel:So, I reached out to Patricia several times to get a response to these allegations, but I never heard from her. The Women’s Help Center declined to comment and they’ve since closed this specific location. But three other women’s health centers are still operating and they’re getting some of that Florida state funding you mentioned earlier. Nadia Hamdan:But what about the Health department’s Investigation? Did they ever do anything with those complaints? Laura Morel:They filed a cease and desist notice against Patricia, barring her from practicing medicine without a license, but The Women’s Help Center didn’t face any consequences like citations or fines. Nadia Hamdan:Wait, how is that possible? Laura Morel:Well, the center isn’t licensed as a medical clinic, which means the State Department of Health doesn’t have any regulatory powers over it. The center’s director also told investigators that it doesn’t provide medical services. And in the end, the agency only dinked Patricia because it’s a third degree felony in Florida for a person to practice medicine without a license. Nadia Hamdan:All right, Laura, so if the State Health Department isn’t watching over these centers, who is? Laura Morel:Well, in most places, no one. So I looked at nearly 1700 CPCs, reviewed pregnancy center industry documents, and talked to dozens of people who are familiar with this issue. And my reporting shows that while about four states do regulate pregnancy centers that provide medical services, the vast majority of states do not require these centers to be licensed or inspected. And that means no one is checking if staff are licensed and properly trained, no one inspecting facilities and equipment to make sure they’re clean and up to date, and no one is protecting clients’ personal information because pregnancy centers don’t have to follow HIPAA. For example, look at Beth’s case. She said Patricia refused to give her back her forms that she had filled out with all of her private medical information. She ended up having to confront Patricia at the center and literally grabbed them out of her hands. Beth:I go, “No, you can’t have any of my information. What you did yesterday was illegal. It wasn’t okay.” Laura Morel:Basically there’s no place people can turn to if they’ve been mistreated or deceived. Nadia Hamdan:Laura, I do think it would be helpful to give a little context here, because when I first learned the history of these pregnancy centers, it really helped me understand that this center in Jacksonville is not just a one-off. These deceptive tactics have actually been baked in from the start. I mean, there was a literal manual that laid it all out. Laura Morel:Yeah, there was. It’s called How to Start and Operate your own Pro-Life Outreach Crisis Pregnancy Center, but most people refer to it as the Pearson Manual because it was written by this guy in Hawaii named Robert Pearson. He was a building contractor, a devout Catholic and was pretty involved in the fight against abortion legalization in the 1960s and ’70s. Nadia Hamdan:And part of that activism included giving pregnant women clothes and diapers. He even added extra rooms to his house so these women could have somewhere to stay. Laura Morel:And that’s why Robert Pearson’s house is actually considered one of the first ever crisis pregnancy centers. Nadia Hamdan:Then in the ’80s, he writes this manual. And, Laura, one of the recommendations in it is almost identical to what Beth experienced. Laura Morel:Right. Here’s what the manual says. “If the girl who would be going to the abortion chamber sees your office first with a similar name, she will probably come into your center.” Nadia Hamdan:Yeah, And he says, the best part of this tactic is that you’re getting free advertising because the abortion clinic is effectively bringing that person to you. Laura Morel:I mean, he’s not leaving much to interpretation. It’s all pretty explicit. For example, one of the recommendations for what to do once you get someone like Beth inside your center is to show them really graphic presentations of what they call the, “horrors of abortion.” To read it directly it says, “If the killing of whales and seals can be shown very emotionally and graphically on TV to stop their deaths, then this is the least that can be done for the pre-born baby and for the mother considering abortion.” Nadia Hamdan:And he goes on to say it’s, “ludicrous to leave the life of a baby as a free and open choice for the mother.” Laura Morel:So there are those in the anti-abortion movement who would say that Pearson was on the fringe and doesn’t represent what many of the centers are doing today. Angela Curatalo:I’ve heard that there’s places that tell them, “Oh yeah, we do abortions. Come on in.” We are not into deceiving people. Laura Morel:Angela Curatalo is the Director of the Respect Life Ministry, which is part of the Archdiocese of Miami. Our reporting partner at the Miami Herald talked to her in April. The ministry has three pregnancy help centers and they’re all near abortion providers. One is even right next door. But Angela says that’s not because they’re trying to trick anyone. It’s just a strategy that makes sense. Angela Curatalo:So that we can reach more abortion vulnerable women and show them what we can do to help them if they so choose. Laura Morel:To, Angela, the centers are just there to help new moms with things like free diapers, wipes and baby wash. Angela Curatalo:There’s people out there who say we lie, we coerce people. We don’t do any of that. Nadia Hamdan:But Jennifer Holland has spent a lot of time studying CPCs and she says- Jennifer Hollan…:They are anti-abortion activists, first. Nadia Hamdan:Jennifer is a history professor at the University of Oklahoma and wrote a whole book about this stuff, called Tiny You. Jennifer Hollan…:They are built on deception, and I don’t think that they think it’s wrong, because it’s the greater good. To them they think they are stopping murder. Laura Morel:And obviously my own reporting with Beth shows that we’re still seeing people using these deceptive tactics. Jennifer Hollan…:The whole idea is someone is seeking an abortion. You think they have already committed to that idea. They are already on their way to a clinic, and you need to create some kind of space that gives the impression that they’re going there and then you can convince them otherwise. Nadia Hamdan:And when it comes to convincing someone not to have an abortion, CPCs found themselves a real game changer. Laura Morel:That’s right. And Jennifer actually interviewed several people about this for her book. Jennifer Hollan…:It’s March 22nd, 2010, and this is Jennifer Holland and I’m here with Mary LeQuieu. Laura Morel:Mary worked at a CPC in Albuquerque, New Mexico. Jennifer Hollan…:We are going to be talking about her activism with the pro-life movement and the history of CareNet in Albuquerque. Laura Morel:CareNet is one of the biggest CPC groups in the United States. And during the interview, Mary says while some CPCs had been known to use these disturbing images and videos- Mary LeQuieu:There was a move that focused on getting away from showing gory pictures. Laura Morel:She says, CareNet found it to be abusive to people who had abortions. Mary LeQuieu:Well, it wasn’t just abusive, it was manipulative. Laura Morel:And by the early ’90s, pregnancy centers had found something to replace those gory images with. Nadia Hamdan:Yeah. It’s called the ultrasound. Mary LeQuieu:I would say that it’s really the big innovation. And we weren’t the first people moving that way, obviously, but we were following the beginning of a national trend. Laura Morel:And Mary said it really did change everything for them. Mary LeQuieu:Because now instead of just talking about it or showing pictures, women could actually see their child on the screen. Laura Morel:And today’s centers use free ultrasounds a lot to get more people to come through their doors. Pretty much the first thing you want to know when you’re pregnant is, “How far along am I?” And CPCs see the power in that. So over the years, they’ve sort of rebranded themselves to look less like a religious charity and more like a medical clinic. Nadia Hamdan:Yeah, I mean Beth even told you that the center she went to looked super medical. Laura Morel:Exactly. The movement knows that offering diapers and baby wipes isn’t enough to stop someone from getting an abortion if they’re already considering one. But an ultrasound image though, that can make a pregnancy feel more real. And as Jennifer points out, the reason CPCs use ultrasounds to convince someone not to get an abortion makes them very different from your standard medical clinic. Jennifer Hollan…:The thing is, CPCs pretend to be parallel institutions. They need to pretend, but they are not parallel institutions. One is a medical clinic who’s committed to health, and the other one is committed first and foremost to a particular political end. Nadia Hamdan:We’ll be back with more from Laura after the break. Special thanks to Clara-Sophia Daly at the Miami Herald for sharing her reporting. So what happens when centers are performing medical procedures without any regulation? Susan Rames:They’re just policing themselves and obviously they’re not doing a good job of policing themselves. Nadia Hamdan:That’s up next on Reveal From the Center for Investigative Reporting and PRX, this is Reveal. I’m Nadia Hamdan, sitting in this week for Al Letson. We’ve been talking about crisis pregnancy centers, places that give out things like free diapers and baby wipes. You can also get free pregnancy tests and ultrasounds, but their real mission is to stop abortions. California passed a law that tried to make centers more transparent with their clients, but the centers fought back, all the way to the US Supreme Court. Reveal’s Laura Morel is back to tell us what went down. Okay, so tell me about this case. Laura Morel:So back in 2015, California really tried to reign in these centers. They passed this law that did two things. The first thing it did is that it required centers to post notices that told clients that California had other reproductive health options like abortion. And the second thing it did was that centers also had to tell clients if they didn’t have any licensed medical staff. Pregnancy centers sued and they said that they were being targeted for their anti-abortion views. And ultimately this case winds up before the US Supreme Court. Speaker 19:We’ll hear argument this morning in case number 161140, the National Institute of Family and Life Advocates verses. Laura Morel:And during oral arguments, Justice Stephen Breyer kept making the point that if doctors who perform abortions have to inform patients about all their options, why shouldn’t centers have to do the same thing? Justice Stephen…:Sauce for the goose, sauce for the gander. I mean, if the law is permissible, which says, “Doctor, you must tell the woman about adoption.” Then why shouldn’t the law say, “Family Planning Center, you must tell the woman about abortion.” Laura Morel:But the lawyers for the pregnancy centers argued that the law Breyer is citing pertains to doctors who perform medical procedures and not CPCs because they don’t do that, that they’re not the same. One is a clinic and the other isn’t. And by forcing these centers to advertise something that they don’t believe in, that violates their freedom of speech under the First Amendment. But Justice Sonia Sotomayor pushes back and she says, “You can’t say you’re not a medical clinic when you’re performing actual medical procedures.” Sonia Sotomayor:I don’t know what an ultrasound is, if not a procedure. I don’t know what a pregnancy test is, if not a procedure. I don’t know how counseling on the pregnancy state is not part of medical advice in the same way a doctor gives it when he’s considering an abortion procedure. I don’t understand the difference. Laura Morel:But Justices Breyer and Sotomayor were in the minority. In June of 2018, the US Supreme Court cited with crisis pregnancy centers. They ruled that California’s law violated the First Amendment. Their decision treats CPCs like religious institutions and essentially frees them from having to comply with standards required of medical providers. Nadia Hamdan:So, Laura, you’re saying because CPCs were able to argue that they’re more like religious institutions, not medical clinics, they can essentially perform medical procedures without any sort of regulation. Laura Morel:Yeah, and my reporting shows there are some real risks because of it. Nadia Hamdan:What have you found? Laura Morel:So I talked to a postpartum nurse in Louisville, Kentucky who volunteered at one of these centers. Her name is Susan Rames and she’s against abortion. Susan Rames:I am a Christian. I believe that it’s important to show women the truth and the life of a pregnancy or what’s happening inside their bodies when they’re pregnant. Laura Morel:Susan ended up volunteering at a place called ALC Pregnancy Resource Center. They were training nurses to perform free ultrasounds for clients so Susan signed up. And she wasn’t getting trained just to do the gel on the belly kind of ultrasound that a lot of people are familiar with. She was getting trained to do transvaginal ultrasounds. Nadia Hamdan:Can you explain what those are for people who don’t know? Laura Morel:So for a transvaginal ultrasound, a technician puts a probe inside the woman’s body. The procedure usually takes at least 15 minutes to get the images. And because it’s more invasive, there’s just a lot more stringent guidelines you need to follow to make sure that everything is disinfected and safe. Nadia Hamdan:So, Laura, why would a center like this be doing this type of invasive procedure? Laura Morel:A lot of women getting ultrasounds at these centers are really early in the first trimester, so they’re only a few weeks into their pregnancies. So if you want to get an image at this stage, you have to perform a transvaginal ultrasound. But obviously there are greater infection risks with this kind of invasive procedure. And Susan knows this well. She’s got nearly 20 years of experience as a registered nurse working in hospitals and maternity wards. Susan Rames:A main theme in healthcare is how do we clean our equipment in between patients, even if it’s as simple as a glucometer that checks blood sugar or anything like that. Laura Morel:So what she saw one day at the center really shocked her. A few months into her training, she noticed a canister of disinfectant hanging on the wall, and this is the disinfectant that staff used to soak the probe after each transvaginal ultrasound exam. But the expiration date, which was scrawled in blue marker, showed the disinfectant had expired about a month earlier. Susan took a photo, which she later showed me. Nadia Hamdan:I mean, I’m not a doctor, but I’m pretty sure you never want to be using anything that’s expired. Laura Morel:And there’s something else that Susan found. There’s a bunch of recent studies coming out of the medical community that say many disinfectants used in hospitals and other places don’t actually kill the human papillomavirus, or HPV, which can cause cervical cancer. And the center was using one of these disinfectants, so it wouldn’t have worked to prevent HPV even if it hadn’t expired. Susan Rames:You are using a probe that’s contaminated and basically passing that on potentially to anybody that you’re using that probe on. Laura Morel:And the medical community is spreading the word about which disinfectants work against HPV. But when you’re a center operating outside of these regulatory standards, it makes it all the more concerning. Nadia Hamdan:But Laura, is this endemic to these centers? How widespread is this kind of thing? Laura Morel:I mean, that’s the problem. We just have no way of knowing because no one is really looking at these centers. There’s no regulatory oversight in place. The only reason I know about this is because Susan decided to speak out and she didn’t just talk to me. Nadia Hamdan:Who else did she speak to? Laura Morel:So first, Susan had a meeting with the center director and a few weeks after that meeting, the director told her that they had changed out the expired disinfectant. They also upgraded their infection control policies. But Susan was still worried because with no oversight, she was concerned that they would just revert back to old practices. Susan Rames:There is no one that is coming in routinely checking on them. They’re just policing themselves and obviously they’re not doing a good job of policing themselves. Laura Morel:Susan decided to quit her volunteer post and filed a bunch of complaints with different state agencies. First, she filed a complaint against the center itself with the Health Department. Nadia Hamdan:But, Laura, we did learn before that Health Departments don’t actually regulate a lot of these centers. Laura Morel:Right, and this is one of them, so they couldn’t do anything. Next, Susan decided to file a complaint against the nurse who was training volunteers and the medical director, who’s a local OBGYN. She contacted the medical board and the nursing board and both agencies investigated, but found there wasn’t enough there to warrant any disciplinary action. I called both boards to understand these decisions, but they wouldn’t go into detail and no one at the center returned my calls and messages. Susan was really frustrated by this point that she couldn’t get any government agency to do anything. The fact that there was this potential for a client to be harmed in this way, it was really weighing on her and she didn’t want this problem to stay hidden. Susan Rames:I don’t think policymakers know that this is happening. I think it’s very sad because it’s taking a vulnerable population. They’re there seeking help. And in turn, they may leave with an infection. We’re not talking about an infection that is just okay, we treat it with seven days of antibiotics. It could be a infection that kills a mom because of cervical cancer. Laura Morel:And, Nadia, I’ve found that in many states, your local tanning salon or pet store faces more oversight than these pregnancy centers, even the ones performing transvaginal ultrasounds. Nadia Hamdan:Okay, Laura, so these centers don’t have to be licensed medical facilities. We’ve learned that. But there are licensed medical professionals working at these places. I mean, we just heard from Susan, who herself is a registered nurse. Laura Morel:Yeah, and that’s why a lot of these pregnancy centers websites will say that they’re a medical clinic. But what that really means is that someone who works or volunteers there has a medical license. Maybe it’s a doctor or a nurse or a sonographer. So they’re piggybacking on those credentials to provide medical services. It’s a system that’s used by other types of medical clinics too, but those facilities face many other additional levels of oversight. And without that oversight, you have situations like the one that Susan found herself in. Susan Rames:You’re saying you want to help these women, for Mom to make the decision to keep her pregnancy and not terminate. So you’re trying to protect them from that evil, but yet you’re going to transmit an infection to them, and it’s okay. It just never made sense to me. Laura Morel:Susan says that what she witnessed during her training made her question the commitment of pregnancy centers to help women and babies. Susan Rames:I have a 22 year old daughter, she just turned 22 in September, who had an unplanned pregnancy in this timeframe. Baby is just now three and a half months old. But when I found out she was pregnant, I said, “Don’t go to any pregnancy centers. Whatever you do, don’t go.” Nadia Hamdan:Laura, Kentucky is one of 14 states where abortion is completely banned, with very few exceptions. What is the likelihood that an anti-abortion state like Kentucky would actually crack down on these centers? Laura Morel:Well, I first wrote about Susan’s story in February, and a Kentucky Democratic State Representative read the piece and decided to try to do something about it. Sarah Stalker:This isn’t a pro-life or pro-choice. You want to play in this space, you have to follow the same rules as everybody else. Laura Morel:That’s Representative Sarah Stalker. She’s especially worried about these centers because reproductive healthcare is so hard to come by in her state. Kentucky has 120 counties and 72 of them don’t even have an OBGYN. Sarah Stalker:It is important to recognize the fact that in some very rural places, if you don’t have an OBGYN, somebody who is a licensed physician, what you might have might be one of these centers. Laura Morel:So she filed a bill this year that would actually create licensing standards for pregnancy centers, things like staff qualifications, maintaining medical records, and infection control protocols. Sarah Stalker:What is deeply concerning to me about these centers is that a lot of them will use the word clinic. That’s false advertising because it makes the individual seeking care, it puts them underneath the impression that the people there are licensed, that they’re certified, that they’re following rules and regulations and things that they’re in fact not doing at all. Laura Morel:Her bill didn’t advance this year, given the state legislature’s Republican super majority, but Representative Stalker plans to file the bill again next year. Nadia Hamdan:Laura, are you seeing anything happening in other states? Laura Morel:So with the overturning of Roe, there are other lawmakers who have been trying to raise a red flag about the pregnancy center industry. We’ve seen bills introduced this year in places like Texas, Arizona, and Minnesota that have all tried to regulate these centers in different ways. Things like making sure centers have licensed medical staff, requiring that only those licensed professionals perform ultrasounds, and strengthening patient privacy protections. While not all of these bills passed, some were successful. In Vermont, for example, the governor signed a bill that would reign in centers using false or misleading advertising. Nadia Hamdan:Laura, if the mission of these centers is to stop abortion, you’d think that they would’ve sort of faded into the background after Roe was overturned, but they just seem to be gaining more influence. Laura Morel:That’s right. More abortion bans means more people will have unwanted pregnancies brought to term. And pregnancy centers want those people to come to them, which is one reason why they’re getting much more funding from states with abortion bans. And in the states where abortion is still legal, CPCs are doubling down on their mission. So the death of Roe v. Wade hasn’t made crisis pregnancy centers irrelevant. It’s actually their moment. Nadia Hamdan:Thanks, Laura. Laura Morel:Thank you, Nadia. Nadia Hamdan:That was Reveal’s Laura Morel. Richard Yeh, Katharine Mieszkowski and Nadia Hamdan, that’s me, produced this show. It was edited by Cynthia Rodriguez with help from Nina Martin. Special thanks to Clara-Sophia Daly at the Miami Herald. And we have some big news. Our new documentary Victim/Suspect is now streaming on Netflix. The doc follows reporter Rachel de Leon’s investigation into a disturbing trend, young women who report sexual assaults to the police and end up as suspects. Stream Victim/Suspect, right now, on Netflix. Nikki Frick is our fact checker and digital producer. Victoria Baranetsky is our general counsel. Our production manager is Steven Rascón. Score and sound design by Jim Briggs and Fernando Arruda. Our CEO is Robert Rosenthal. And our COO is Maria Feldman. Our interim executive producers are Brett Myers and Taki Telonidis. Our theme music is by Camerado-Lightning. Support for Reveal is provided by the Reva and David Logan Foundation, The Ford Foundation, the John D. & Catherine T. MacArthur Foundation, The Jonathan Logan Family Foundation, The Robert Wood Johnson Foundation, The Park Foundation, and The Hellman Foundation. Reveal is a co-production of the Center for Investigative Reporting and PRX. I’m Nadia Hamdan, and remember, there is always more to the story.