ST. LOUIS, MO — Today, the House of Representatives Committee on Oversight and Reform held a hearing examining efforts by the state of Missouri to restrict access to legal abortion care. Following the hearing, Executive Director of NARAL Pro-Choice Missouri, Mallory Schwarz, released the following statement:

In recent years, under the leadership of Republican Governor Mike Parson, the Director of the Missouri Department of Health and Human Services Randall Williams has co-opted public health into a tool of abuse and injustice. From weaponizing the licensure process to deny the state’s only abortion provider its license, to forcing an invasive, medically unnecessary pelvic exam on more than one hundred Missourians, Williams has jeopardized the health of 1.1 million women, trans and non-binary people of reproductive age, denying them the health care they need, want, and deserve. 

No doubt Williams’ efforts will serve as a template for other similarly situated states, and thus we are grateful that the Committee is choosing this moment to focus on access to health care in Missouri and the egregious actions of Missouri’s leaders. 

NARAL Pro-Choice Missouri members Robin and Jim Utz are advocates for abortion access, not because they “have always been passionate about abortion, but [because] we ARE now the face of the issue. Our desperately-wanted daughter is the issue.” Robin and Jim became the face of this issue in 2016, when their wanted pregnancy– their desperately-wanted daughter, named Grace in-utero– was diagnosed with Multicystic Dysplastic Kidney Disease, a condition 100% fatal at such an early onset, having been identified in both kidneys. 

In Robin’s own words: “The process the state has for obtaining an abortion is one of the most difficult things I have ever experienced. Because we learned about Grace’s diagnosis at 20 weeks 6 days and we had to wait 72 hours to have the procedure done after signing consents (no exceptions are made for those with a fetal anomaly), we had virtually no time to consider our options before we’d run into the limit of 21 weeks 6 days. Had, for instance, a 20 week abortion ban been put into place, we would have had to have left the state. 

I shouldn’t have to leave the state to take care of myself and my family. I have lived in Missouri for all of my 37 years. I got my Bachelors and Masters degrees here. I love this state, and am proud to pay taxes and vote in every single election I can here. My family and I deserve to have the state laws include us and those like us.” 

Robin and her family were forced to face huge obstacles in Missouri to access needed abortion care due to the restrictions placed on accessing abortion by both the state legislature and the very health department charged with protecting the public health of Missourians. 

Over the past decade, the Missouri General Assembly has systematically stripped Missourians of their access to legal abortion through the targeted regulation of abortion providers, or “TRAP” laws — costly, severe, and medically unnecessary requirements imposed on abortion providers and reproductive health centers. Missouri imposes these extra restrictions on abortion providers, despite the fact that all health-care providers already must comply with a variety of federal and state regulations governing health, safety, building and fire codes, and zoning requirements. 

Among the most common TRAP regulations are those restricting the provision of abortion services to hospitals or other specialized facilities, which place medically unnecessary and costly requirements on doctors and can decrease the availability of abortion care for women. Missouri has such regulations, including: 1) Abortion providers must be located within 30 miles of a hospital, or face criminal penalties. No exception is provided for rural areas; 2) All abortion providers must have staff privileges at a hospital within 15 minutes’ travel time or maintain a working arrangement with a hospital within such a distance. Nothing requires the hospital to grant providers such an arrangement; 3) Missouri regulations require each provider to be licensed as an “abortion facility” if 51 percent or more of its patients receive abortion care, or if 51 percent or more of its revenues are “from abortions or procedures related to abortions” Mo. Code Regs. Ann. tit. 19, §30-30.050(1)(A), (B), .050(2)(A); 4) Facilities that were built after the rule was put into effect in 1987 must comply with dozens of medically unnecessary administrative, professional-qualification, patient- and employee-testing, and physical-plant requirements. These include particularly costly and onerous construction and design requirements, such as that procedure rooms must be at least 12 feet long and wide with ceilings at least nine feet high and doors at least 44 inches wide, corridors must be at least six feet wide, and separate counseling rooms are required and must be at least 10 feet long and wide; 5) Missouri passed another law that would require most, if not all, health-care facilities that provide abortion care in Missouri to become licensed “ambulatory surgical centers.” Becoming an ambulatory surgical center is a highly burdensome and unnecessary process that would force providers to make even more expensive and time-consuming changes to their facilities than are already required; 6) Missouri has an unconstitutional and unenforceable statute that requires all abortion services after 16 weeks be provided in a hospital. 

Missouri also prohibits certain qualified health-care professionals from providing abortion services. Only a physician licensed by the state to practice medicine in the state and having surgical privileges at a hospital that offers obstetrical or gynecological care may provide abortion services. This restriction prevents otherwise qualified certified nurse midwives, or nurse practitioners from practicing to the full scope of their training and skill, and further limits access to abortion care. 

Additionally, a pregnant person may not receive abortion services until at least 72 hours after receiving a state-mandated lecture containing medically inaccurate information from the abortion provider. The provider is required to discuss with them the “indicators and contra-indicators, and risk factors including any physical, psychological, or situational factors for the proposed procedure and the use of medications, including but not limited to mifepristone, in light of her medical history and medical condition.” The law also requires the woman to receive materials that state that “the life of each human being begins at conception. Abortion will terminate the life of a separate, unique, living human being.” Mo. Rev. Stat. § 188.039 (Enacted 1979; Last Amended 2014). 

As a result of these cascading restrictions on health centers offering abortion services , abortion 1 is now out of reach for the majority of reproductive age people in our state. All of these restrictions went into effect before and regardless of the recent direct bans on the provision of abortion care, and have resulted in the closure of all but one health centers in the state that offered abortion care. Missouri is now one of six states in the nation with only one remaining abortion provider. 

Compounding the impact of these anti-choice legislative efforts, are the recent actions by the Missouri DHHS, misusing the regulatory system to further undermine access to this basic health service. Perhaps most egregious of these attacks is the proposed rule that would force providers to administer an invasive pelvic exam at least 72 hours before a nonsurgical abortion. This requirement of a pelvic examination prior to an abortion, including medical abortion, is opposed by health care providers, including the American College of Obstetricians and Gynecologists (ACOG), the nation’s leading women’s health providers. In June, 2019, health care providers resisted this medically unnecessary rule, stating that it only puts patients in more danger, especially patients who are survivors of sexual assault. According to ACOG, subjecting women to this invasive procedure when there is no medical benefit or purpose is coercive and puts patients at risk of unnecessary trauma. At best, even medically necessary pelvic exams are uncomfortable, but for survivors of previous trauma, they can be devastating. Requiring a pelvic exam that medical providers themselves have deemed unnecessary amounts to state-sanctioned assault. 

1 Of note, this is not an exhaustive list of restrictions on abortion providers in Missouri. Please see: https://prochoicemissouri.org/laws-policy/state-laws/ for more information 

Rather than listen to the recommendations of the medical community, the state believes they should decide when and how patients should receive pelvic examinations. Two years ago, agency officials agreed with Planned Parenthood’s decision to perform pelvic exams only when medically necessary — on the day of a surgical abortion. Since Randall Williams became Director of the DHSS, however, more than one hundred Missourians have been subjected to a medically unnecessary pelvic exam against the will of both patients and their providers. 

Most recently, and vibrantly in the national attention, are the current and ongoing efforts to shutter the last remaining provider in the state: Reproductive Health Services of Planned Parenthood of St. Louis and Southwest Missouri (RHS). This clinic is being targeted despite a strong safety record and consistently acting in compliance with existing regulations, and their ability to continue providing care is currently jeopardized by the current licensing hearing. 

In a testimony during the recent RHS licensing hearing Randall Williams admitted to using a spreadsheet to monitor the menstrual cycles of those who visited Planned Parenthood of the St. Louis Region. The spreadsheet kept by the state included personal health information for each person including the date of their last menstrual period. Members of the DHSS, at the request of the Director, used this private information to track if these people had visited Planned Parenthood more than once to have an abortion. Rightly so this revelation has garnered national attention and outrage, but few are more outraged than those who have sought or accessed abortion care in the past. From Robin Utz, “The idea that my deeply personal decision would be tracked for a political agenda makes me feel sick to my stomach. It is just another example of how the state doesn’t just fail to respect our privacy and humanity, but actually treats us as entities not deserving of trust, and as political pawns.” 

Abortion is still legal in Missouri. However, for many Missouri residents in underserved or marginalized communities, the right to abortion exists in name only. Without the means to pay for a service that on average in the first trimester costs on average $500, and often more than $1000 after the first trimester gestation; without the access to transportation to travel across the state, or out of state to access a provider; without the resources for potential childcare; the job security to be able to take time off from paid employment; without these privileges and means, most Missourians are already without access to this essential health service. 

There are six health centers that offer abortion in neighboring states that serve as the nearest clinic to Missouri residents: Hope Clinic for Women in Granite City, Illinois; Planned Parenthood in Fairview Heights, Illinois; Center for Women’s Health in Overland Park, Kansas; Planned Parenthood North Central States in Des Moines, Iowa; Emma Goldman Clinic for Women in Iowa City, Iowa; and Little Rock Family Planning Services in Little Rock, Arkansas. The average distance a Missouri patient must travel to reach one of these clinics is 78.18 miles each way. This number was determined through an internal investigation by NARAL Pro-Choice Missouri and calculated by examining each county in Missouri to determine which out-of-state clinic was closest, then finding the shortest driving distance available from each county to their respective nearest clinic. These distances were compiled, weighted by estimated number of women of reproductive age in each county, and averaged to 78.18 miles. 

This number is the average one-way distance for a Missourian person of reproductive age to travel to an out-of-state clinic providing abortions, meaning the average for one round-trip to a patient’s respective nearest clinic would be 156.36 miles. This calculation also does not account for the potential need to make multiple trips, due to waiting periods or other logistical considerations. To make this trip twice a patient must travel a total of 312.72 miles. It is clear that the cost of such a trip, in distance, in transportation, in potential childcare, in time away from paid employment, constitutes a significant burden on the people of Missouri. 

Every Missourian has the right to access to access the full range of reproductive health options, including preventing unintended pregnancy, bearing healthy children, and choosing legal abortion. NARAL Pro-Choice MIissouri will not stop fighting until this right is a reality for all Missourians. We once again thank the Committee for highlighting the disparities in access in Missouri, and for the opportunity to submit a statement for the record.

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