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Kansas City’s historic northeast pushes back against proposed school closures

2 years 7 months ago

This story was originally published by the Kansas City Beacon.  Gregg Lombardi estimates the Lykins neighborhood in northeast Kansas City is on track to win the battle against blight by next year. The Lykins Neighborhood Association and Neighborhood Legal Support of Kansas City, both of which Lombardi directs, have been working to support residents and make abandoned homes […]

The post Kansas City’s historic northeast pushes back against proposed school closures appeared first on Missouri Independent.

Maria Benevento

After a Stillbirth, an Autopsy Can Provide Answers. Too Few of Them Are Being Performed.

2 years 7 months ago

After Dr. Karen Gibbins’ son was stillborn in 2018, doctors could not explain why it happened.

She underwent genetic testing, which came back normal, and an examination of her placenta, which her medical records show was “notable for the lack of evidence” of an infection or any abnormalities.

But Gibbins didn’t give up hope of finding an answer. She had also asked for an autopsy.

For Gibbins, a maternal-fetal medicine specialist at Oregon Health & Science University who has published research on stillbirths, her son’s death in her 27th week of pregnancy hit painfully close to home. Her expertise added urgency to her desire to understand what had gone wrong.

When the final autopsy results came back about six months later, she was stunned to learn that her son, whom she had named Sebastian, had a rare disease caused by her antibodies attacking the cells in his liver.

By then, Gibbins, who had a son at home, had learned she was pregnant again. She forwarded the report to her doctor, who started her on grueling weekly infusions of antibodies. When she suffered an unrelated complication at 32 weeks and began bleeding heavily, her doctor delivered her baby immediately.

Where there was silence after Sebastian’s birth, Everett cried when he was born.

Gibbins with her two living sons at her family’s home in Portland (Kristina Barker, special to ProPublica)

“If we had not had that autopsy,” Gibbins said, “my third child would have died as well.”

Researchers and national obstetric groups, including the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, have called on doctors and hospitals to offer a stillbirth evaluation, a systematic assessment that includes placental exams, genetic testing and autopsies.

But too often they are not done, making the already complex task of determining the causes of death even more difficult. In about one-third of stillbirths, the cause of death is never determined, according to a recent Centers for Disease Control and Prevention report.

Some doctors do not offer patients the postmortem exams after a stillbirth; some patients decide against them without fully understanding the potential benefits. The federal government doesn’t cover the cost of an autopsy after a stillbirth, though many experts say it should be viewed as a continuation of maternal care.

Research has shown that placental exams may help establish a cause of death or exclude a suspected one in about 65% of stillbirths, and autopsies were similarly useful in more than 40% of cases.

While placental exams, autopsies and genetic testing are all recommended, at the very least the placenta should always be tested, said Dr. Drucilla Roberts, a perinatal pathologist at Massachusetts General Hospital and professor of pathology at Harvard Medical School.

“It’s the heart and lungs of the baby” while in the womb, said Roberts, who added, “The placenta should definitely be evaluated in every stillbirth.”

But in 2020, placental exams were performed or planned in only 65% of stillbirths, the most recent CDC data shows. Meaning that in thousands of stillbirths that year, the placenta was thrown out without ever being tested.

Autopsies are performed in even fewer cases. Those exams, according to CDC data for 2020, were conducted or planned in less than 20% of stillbirths.

Experts blame the low rates on several factors. Because an autopsy often is performed in the days following a stillbirth, doctors and nurses have to ask families soon after they receive news of the death if they would like one. Many families can’t process the loss, let alone imagine their baby’s body being cut open.

What’s more, many doctors aren’t trained in the advantages of an autopsy, or in communicating with parents about the exam. Doctors also often don’t tell patients that, for example, families can still have an open casket funeral after an autopsy, because the incisions are done in such a way that they can easily be covered by clothing.

“I think a lot of times there can be misconceptions among providers,” said Dr. Jessica Page, an assistant professor and maternal-fetal medicine specialist at University of Utah School of Medicine and Intermountain Healthcare. And if doctors aren’t providing compassionate and informed counseling on the potential benefits of the exams, patients may lose the opportunity to learn why their child died.

“It impairs our ability to give them thorough counseling regarding risk in future pregnancies,” Page said. “It’s hard to reduce the rate of stillbirth if we don’t understand why they all happen.”

Page is working to help doctors better counsel patients about autopsies following a stillbirth, and she and Gibbins are planning to apply for a federal grant to develop a step-by-step tool to walk patients through the autopsy process.

The need for evaluations is underscored by the current stillbirth crisis. Every year more than 20,000 pregnancies in the U.S. end in stillbirth, the death of an expected child at 20 weeks or more. About half occur at 28 weeks or more, after the point a fetus can typically survive outside the womb.

But the stillbirth rate has received little public attention, which has been made worse by insufficient research and the experience of some mothers who have complained that medical professionals ignored or dismissed their concerns. One study found that nearly one in four U.S. stillbirths may be preventable.

In the summer of 2020, Kendra Skalski arrived for her doctor’s appointment with her hospital bag packed. It was a day before her due date, and she was uncomfortable and ready to deliver. Skalski asked her doctor what the earliest date was that she could have a scheduled delivery, but she said her doctor told her not before 41 weeks.

This was her first pregnancy, and Skalski said she didn’t know she could push back.

But hours before Skalski was scheduled to be induced, she realized she hadn’t felt the baby kick. She called her doctor’s office and was told to head in to the hospital early. Skalski said the person she spoke to didn’t sound worried, so Skalski wasn’t worried either.

“I just remember thinking everything was fine,” Skalski recalled.

At the hospital, the staff collected her insurance information. She laughed with her husband, a New York City firefighter, as she filled out the paperwork.

When the nurse struggled to find the baby’s heartbeat, Skalski thought the monitor was broken. She searched her husband’s face, staring intently at his eyes, hoping for reassurance. “Everything is going to be OK,” he told her.

Then a doctor confirmed that her baby, a girl she had named Winnie, didn’t have a heartbeat.

“This isn’t happening,” Skalski recalled saying. “This isn’t happening.”

Skalski couldn’t comprehend her loss, let alone the decisions she then had to make. Induce the delivery of her dead daughter or go home and come back in the morning? Vaginal delivery or cesarean? Burial or cremation? Placental exam or autopsy?

The doctor, she said, told her an autopsy likely wouldn’t find anything. Skalski also struggled with her own feelings of guilt; she wouldn’t be able to live with herself, she said, if the autopsy revealed that she had somehow caused her daughter’s death. And the thought of someone cutting open her daughter left her distraught. She said no to the autopsy.

She now regrets that decision. The doctor had asked her about the autopsy before she had even delivered her daughter, she said, and no one explained to her that she might want the results after the shock wore off.

“I wish that I had been more well-informed,” she said. “I wish that someone had said, ‘OK, this is nothing that you did. Let’s find out what it was.’”

Skalski said she chose Northwell Health, New York State’s largest health care provider, because of its reputation. A spokesperson for Northwell Health did not answer questions about Skalski’s care but said its hospitals follow ACOG guidelines and consider inducing a mother between 41 and 42 weeks, though doctors weigh a variety of factors, including communication with expecting mothers, “in order to provide the best possible care for each individual patient.”

In addition to possibly helping her understand why her daughter died at 41 weeks, the autopsy could have offered her and her doctors some clarity when she got pregnant again. Skalski became the inaugural patient of the Rainbow Clinic at Mount Sinai Hospital in New York City, the first of its kind in the U.S., which is modeled on similar clinics in the United Kingdom that employ specific protocols to care for people who have had a stillbirth.

In August, Skalski gave birth to her daughter, Marigold.

Although general pathologists can perform autopsies and placental exams, perinatal pathologists undergo specialized training to help them know what to look for in cases of stillbirth. By all estimates, the U.S. is currently suffering from a shortage of perinatal pathologists, said Dr. Halit Pinar, a longtime perinatal pathologist and professor at The Warren Alpert Medical School of Brown University. He worries that recruiting a well-trained perinatal pathologist after he retires will be a challenge.

“Perinatal pathology is not glorious,” he said.

Younger doctors know choosing another pathology specialty may be a more secure professional path, he said, but perinatal pathology is critical, and autopsies after a stillbirth are essential. Some of Pinar’s most rewarding moments have come from being able to provide closure to mothers and explain that they are not to blame.

When his team received a federal grant that covered autopsies through the Eunice Kennedy Shriver National Institute of Child Health and Human Development, which is part of the National Institutes of Health, the stillbirth autopsy rate reached around 95%, he said. Once funding ended, he said, the number of autopsies fell to around 30% to 35%.

Medicaid, he said, should consider paying for autopsies after stillbirths as an extension of postpartum coverage.

“If there is reimbursement, so that it’s not on the shoulders of the hospital budget, it is going to help,” Pinar said. “This is part of maternal care.”

Many larger academic hospitals absorb the cost of autopsies, but some families have said uncertainty around whether the cost of the autopsy was covered affected their decision not to have an autopsy done.

A spokesperson for the Centers for Medicare & Medicaid Services said federal payment for autopsies is not permitted because Medicare and Medicaid laws do not allow for their coverage.

The Stillbirth Health Improvement and Education (SHINE) for Autumn Act, a bill co-sponsored by U.S. Sens. Marco Rubio, R-Fla. and Cory Booker, D-N.J., seeks to improve stillbirth research by providing training in perinatal autopsies, but the legislation has not passed the Senate.

Even if a family wants an autopsy, it doesn’t guarantee that it will happen.

Stephanie Lee’s daughter, Elodie Haru Ansari, was stillborn last year.

Lee was 36 weeks pregnant, though her belly was so big people frequently asked if she was having twins. Still, medical records show Elodie weighed 3 pounds, 10 ounces at birth. Lee, a registered nurse, said her doctor had suspected her daughter might have had a birth defect where her esophagus did not develop properly.

Lee and her husband, Tunaidi Ansari, wrestled with so many unanswered questions that there was no doubt in their minds about the autopsy. Lee signed the paperwork to have one performed.

They waited for weeks to receive the results, but when they never arrived, she asked her doctor about the delay. The doctor called her, and only then, she said, did she and her husband learn that the hospital never performed the autopsy.

“We were promised an autopsy,” Ansari told the doctor. “We were promised every single thing to test for, and the most basic thing was the autopsy, which they said was done on the same day or the next day, and we don’t have it.”

As he spoke, Lee sobbed.

A hospital administrator later wrote Lee a letter that explained that the autopsy consent form was not sent to the correct office, and “as a result, the morgue was not made aware of the request for autopsy.” In light of the “break-down in communication,” the administrator said, the hospital was updating its procedures. “Although it is not possible to change the outcome in your case,” she wrote, “I want to assure you that all measures are being taken to prevent a circumstance like this from ever occurring again.”

Neither Weill Cornell Medicine, where Lee received her care while pregnant, nor NewYork-Presbyterian Alexandra Cohen Hospital for Women and Newborns, where she delivered her stillborn daughter, responded to requests for comment.

On a recent Friday, Lee, who is pregnant with her second child, gathered her family to celebrate what would have been Elodie’s first birthday. She hung a banner and balloons above a table filled with stuffed animals, flowers and photos of Elodie. In the center was a five-layered tteok cake, a Korean rice cake traditionally served when a child turns one.

Later that evening she held the urn with Elodie’s ashes next to her belly and said goodnight to both her daughters. The next morning, she ordered her coffee as usual, under the name “Elodie.”

Stephanie Lee and her husband, Tunaidi Ansari, are now expecting their second child. (Stephanie Mei-Ling, special to ProPublica)

Help Us Report on Stillbirths

by Duaa Eldeib

Of All Things, Progressive Bipartisanship

2 years 7 months ago
The midterms displayed a polarized America. Paradoxically, the thin Republican House majority and some substantive areas of convergence produce opportunities.
Robert Kuttner

She Wanted an Abortion. A Judge Said She Wasn’t Mature Enough to Decide.

2 years 7 months ago

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

This article was produced in a partnership between ProPublica and The New York Times Magazine. It is not subject to ProPublica's Creative Commons license until Dec. 28, 2022.

On a hot Texas morning in 2020, Giselle, who goes by G, slipped her arms into a borrowed blazer, flipped up the nose ring in her septum so it couldn’t be seen and walked into the Coryell County Courthouse. It was the first time she had ever been to court. She was 17, 11 weeks pregnant and already beginning to show. She was going to ask a judge for authorization to seek an abortion. Her lawyer had explained that she needed to prove that she was mature enough to make this decision. G squeezed her lips around her braces, reminding herself not to smile. She didn’t want the judge to see her as a child.

Because G was a minor, her access to an abortion was governed by the state’s “parental involvement” law. She could have either notified her mother or father and gotten consent, or she could have filed a petition in her home county, asking for what’s known as a judicial-bypass hearing. She had chosen to petition. In the carpeted courtroom, G explained that she didn’t know her father, who was investigated by Child Protective Services after being accused of molesting her when she was a toddler. Though the case was inconclusive and he denies abusing her, he eventually gave up his parental rights. G didn’t trust her mother, whom she viewed as unreliable and volatile. They had bounced among houses and boyfriends for stretches of G’s life. A year before, G packed up her things and left.

G at 16 in June 2019, on a trip to a lake with her friends (Archival photo by Parker Hill and Isabel Bethencourt)

When she discovered she was pregnant, she traveled to an abortion clinic in Austin, about 60 miles south of where she lived in Copperas Cove, a city of 37,000 where nearly everyone works on Fort Hood, the nearby military base. The clinic referred her to Jane’s Due Process, an organization that helps minors navigate judicial bypass. Ten days later, its staff found G a trained attorney. It took G a week to schedule a ride to meet with the lawyer, who asked about her grades, extracurricular activities, babysitting experience and which birth control method she would use in the future. Then, before her court date was scheduled, the District Court judge assigned to the case recused himself. Although he didn’t say why, many judges choose not to take a case in which they might have to approve an abortion. The clerk needed to book a visiting judge. Altogether, G had spent four weeks trying to get a hearing. And now, on June 18, 2020, four months shy of her 18th birthday, G knew that her future was at this judge’s discretion.

“Have you had to deal with your mom dealing with your braces?” her lawyer asked, hoping to show the judge that G couldn’t depend on her mother. Since she left home, G explained, her mother had been withholding payment on her braces, telling the orthodontist that G needed to cover the cost.

When her lawyer asked her why she was seeking an abortion, G said she didn’t think she would make a suitable parent. She had just graduated from high school and was working as a cashier at the H-E-B supermarket chain. Her goal right now was “taking care of myself and financial needs to the best of my ability.” She had broken up with her boyfriend, Cecil, after she found out she was pregnant, concerned that he wouldn’t be there for her. Neither of them believed that they were ready to raise a child. He didn’t make enough as a brick mason to move out of his parents’ house, and for a year, G had been crashing with friends. An abortion, she believed, would be “in the best interest of the fetuses.”

She had thought about adoption, she told the judge, but it was not for her. “I don’t feel like I can grow something in my body for nine months and then physically hand it away.” When her lawyer asked her what she expected after the abortion, G regurgitated the warnings from “A Woman’s Right to Know,” a Texas Health and Human Services pamphlet that her lawyer told her to study in preparation for the hearing: She would bleed, cramp and feel emotional and depressed. G told the judge that she had made a list of pros and cons in her journal: “Cons: Killing something growing inside of me. Guilt. Constant guilt from others. Pros: Continue life without being pushed back. Freedom.”

The judge said he had a few questions. “I probably misheard you, but I thought you said ‘fetuses,’ instead of ‘fetus.’”

G winced, annoyed with herself for using the plural. “It’s two,” she said. Twins. The judge wanted to know if she had received counseling at the abortion clinic. “Did they give you, for instance, any statistics about how many women regret or don’t regret it five, 10, 12, 20 years from now?” They hadn’t.

“I’m basically standing in the stead of your parents by making this decision,” the judge continued. “In doing so, I want to make sure that I would treat this as if you were my daughter.” G tried to control the muscles in her face. She didn’t want to reveal her frustration that this gray-haired man with deep-set eyes was imagining himself as her father, whom she had feared since she was a child. The judge explained that he wanted to take the long view, focusing on her health. This is a high-risk pregnancy, G thought, or at least that’s what the clinic told her. If he cared about my health, he would say yes to an abortion. “Obviously, it’s a monumental decision,” he said. “It’s a life-changing decision.”

The judge told G that he didn’t want to rule immediately. First, he wanted G to visit a crisis pregnancy center and have an ultrasound. He recommended two Christian organizations that counsel women to keep their pregnancies. G replied that she had tried to go to one in town, but it was closed because of COVID-19. The judge said he wanted her to try another. Under Texas law, the names of judges in bypass hearings typically remain unknown, so what the judge said next was striking. He gave G his cellphone number and told her to call him once she attended her appointment. “I’m a judge in Waco,” he said, adding that his name was David Hodges.

At 73, Hodges is retired, though he still fills in on cases. He served as a county-level judge until 2002, when he violated the state’s election code by running as a Democrat but voting as a Republican. The Democratic Party removed him from the ballot, and he stepped down as a full-time judge. Hodges has ruled on about a dozen judicial-bypass cases. He hates them, he told me — none of his peers want to be the arbiter in these hearings. He sees his role as similar to that of a jury determining whether a convicted criminal defendant “should be given life in prison or the death sentence,” he said. “I consider this decision to have that kind of weight.” He told me he didn’t want to impose his personal views about abortion on G — he believes that life begins soon after a fetal heartbeat — but he did want her to have an ultrasound, because “statistically, if the proposed mother is shown the ultrasound, they will change their mind and decide they don’t want to have an abortion.”

G knew none of this, but she was aware that crisis pregnancy centers opposed abortion. As she walked out of the courtroom, her lawyer tried to reassure her. “Maybe he is saying if you do this, he will grant it?”

The next morning, G caught a ride 50 miles south to a crisis pregnancy center, where a woman displayed her ultrasound on a large screen and turned up the volume of the fetal heartbeats, which sounded like galloping hooves. The woman read off the supposed risks of abortion — the chance of death, the likelihood of infertility — and printed photos titled “Baby A” and “Baby B.” G left the center frightened and angry and immediately called her lawyer to file an affidavit. “I am walking into this situation thankful for all the information and care I have received,” the document read. “I am asking the court to sign an order allowing me to have an abortion.”

That afternoon, G’s lawyer called her. Hodges had denied her petition, ruling that she wasn’t mature enough to make this decision. G could appeal, the lawyer said, but G’s mind was already replaying her testimony. She had stuck to the conventions of the bypass hearing, spinning a story about her life that portrayed her as an upright woman: She was studious and diligent at work; she could save money and pay bills. Now she just wanted to do it over. Her life was a mess, a loop of false starts, deferred plans and upheaval. All she wanted was to tell the judge the truth: She wasn’t mature enough to be a mother.

G holds a photo of herself taken during her pregnancy, “pretending to be happy,” she says.

Parental-involvement laws were some of the first abortion restrictions passed after the Supreme Court’s 1973 decision in Roe v. Wade, and they are one of the few on which voters across the political spectrum have long agreed, with roughly 70% of adults in favor of them. When the court ruled in June on Dobbs v. Jackson Women’s Health Organization, overturning Roe, 36 states enforced these statutes. Some require minors to notify a parent; others require them to get the consent of one or both parents. Several require that they do both. If a minor chooses not to involve a parent, she must prove to a judge that she is mature and well-informed enough to make a decision about abortion. Or, depending on the state, she can prove that having an abortion, or doing so without involving her parent, is in her best interest.

To their supporters, these laws are common sense: Parents have responsibility for their child’s well-being, and it’s reasonable that they be involved in ending a pregnancy. When Bill Clinton ran for president in 1992, he explained on MTV that he had signed a parental-notification law as the governor of Arkansas because, after an abortion, “who helps the kid pick up the pieces?” Teenagers, especially younger ones, may not be mature enough to make a well-thought-out choice about abortion, proponents argue. For the past century, the Supreme Court has also recognized the authority of parents to raise their children as they see fit — in their education, religion, health care. If a school nurse determines that a child would benefit from Advil, the nurse usually needs permission from the child’s parent before administering it. With a decision as charged as abortion, most parents similarly want to be consulted. Lawmakers say that requiring minors to engage their parents offers protection, honors a family’s values and encourages dialogue at home.

Critics of the statutes point out that most teenagers involve their parents in their abortion decision regardless of state law. Opponents are especially concerned for teenagers who live in homes that are abusive, neglectful or otherwise unsafe. The American Medical Association and the American Academy of Pediatrics have each noted that although a parent’s involvement is helpful in many cases, a mandate introduces the risk of violence or rejection for young people in unsupportive families. The Academy of Pediatrics also finds that it delays care. Youth advocates point to the hundreds of thousands of minors in the United States who don’t live with their biological or adoptive parents — those in foster care or staying with relatives. Or they talk about the rights that they believe young people deserve, regardless of whether their parents are dangerous. “It’s not just about young people as victims,” says Jessica Goldberg, who works for the reproductive rights group If/When/How on reducing barriers for young people and eliminating the statutes. “Forced parental involvement in the abortion decision ignores all young people’s bodily autonomy.”

The judicial-bypass procedure has been presented as a compromise, balancing the interests of teenagers and their parents. Almost every state that requires parental involvement includes the option for a minor to go before a judge instead. The compromise hinges on the belief that the hearings are fair, efficient and shielded from politics. In states where clinics connect teenagers with experienced attorneys and where the court staff is trained, the process can go smoothly. In others, it’s a crapshoot. The question of “maturity” is open to wildly different interpretations, particularly when assessed by a judge who answers to voters. In many counties, teenagers who try to file petitions find courts that are unprepared or biased; research surveys have shown that it’s common for staff to turn away callers or delay bypass hearings. Judges sometimes announce their intention to issue denials before the hearing or try to persuade teenagers to carry their pregnancy to term; in Alabama, one judge announced, “This is a capital case,” and suggested that the petitioner would be damned to hell. In a 2020 study on attorneys’ experiences in Texas, lawyers recounted regular activism on the bench. One judge told minors to “refrain from any sex prior to marriage.” Others appointed counsel who spoke out against abortion.

The most recent data indicates that about 90,000 minors become pregnant each year, and 25,000 end their pregnancies. Compared with adults, teenagers have a tougher time coming up with money for an abortion and, if they don’t have a car or a license, more trouble getting to a clinic. They are much less likely to have a credit card to order abortion pills online. Because their periods aren’t as regular, they tend to detect their pregnancies later. No one knows how many teenagers across the country can’t get abortions because of parental-involvement laws. There’s no count of those who are denied by judges or those who want an abortion but can’t come up with a way to travel or skip school or find a lawyer. Because the cases are sealed, even the number of bypass petitions filed each year is a mystery. Several lawyers told me that they know only the initials of their teenage clients, and many shred the files after hearings. Before the Supreme Court reversed Roe, in 12 states where some numbers were available — compiled by researchers, attorneys or public health departments — around 1,000 total petitions were filed yearly.

Legislators began passing parental-involvement laws in the mid-1970s, as liberals and conservatives came to believe that curbing teenage pregnancy would improve the economic lives of young women and cut costs for the government. But over the past several decades, evidence has suggested that instead of changing the sexual behavior of teenagers, these laws push many young women into motherhood before they want it. Given the Dobbs decision this summer, the consequences of these restrictions will most likely become more pronounced.

Without the protection of Roe, almost every state in the South and the Great Plains is expected to ban or severely limit abortion, denying access to both adults and minors. As state courts weigh in on abortion restrictions, the laws continue to shift; at the moment, 14 states are poised to protect the right to abortion and do not have, or do not enforce, parental-involvement laws (Alaska, California, Connecticut, Hawaii, Illinois, Maine, Minnesota, Nevada, New Jersey, New Mexico, New York, Oregon, Vermont and Washington). More than 20 still allow most abortions and also maintain parental-involvement laws. Several of these states — including Florida, Kansas, North Carolina and Pennsylvania — border regions of the country where abortion is being criminalized. They are among the closest options for teenagers in states with bans.

14 States Ban Most Abortions, and 22 More Require Teens to Get Approval From a Parent or a Judge

The 14 states, plus Washington, D.C., that allow minors to seek abortions without an adult’s approval are often hundreds of miles away from teens in the South and Great Plains.

Note: States are marked as banning all or most abortions if they have blocked abortions after the sixth week of pregnancy and are currently enforcing that ban; some additional states’ bans are not currently in effect due to litigation. This data is current as of Nov. 28, 2022. (Map combines data obtained by ProPublica with data published by If/When/How; map by Lucas Waldron, ProPublica)

The farther a teenager needs to travel to a clinic where they can consent to an abortion on their own, the less likely they are to end their pregnancy. From 1992 to 2015, as parental-involvement laws proliferated, the distance the average minor would need to travel increased from 58 miles to 454 miles. “You can see the country closing in on teens,” says Caitlin Myers, a professor of economics at Middlebury College who mapped this changing landscape in a recent paper. She estimates that in this time, parental-involvement laws were responsible for 108,000 additional teenage births.

As new bans take hold, driving distances will grow longer for many teenagers who want an abortion. An adult in Dothan, Alabama, for example, could travel 90 miles to Tallahassee, Florida, for the procedure. A 17-year-old would have two options: She, too, could go to Tallahassee, but she would have to file a petition, which the court would ask her to write herself before she is appointed an attorney. If she tried to visit an abortion clinic to learn the facts of the procedure, the clinic would refuse to schedule a consultation without judicial authorization. She would attend her bypass hearing, where a judge would expect her to know the medical risks of an abortion. The judge would have three days to decide how to rule. In many circumstances, the teenager would need to do this without alarming her parents by going missing. Her second option would be to travel to the nearest clinic in a state without a parental-involvement law — in Carbondale, Illinois, 590 miles away. Or, faced with these choices, she might weigh a third option: She could give up.

For Millions of Teens, Getting an Abortion Can Mean Traveling to Illinois, Washington, D.C., New Mexico or Minnesota Note: The distance from each county to the nearest abortion provider was calculated using the population center of each county and road networks generated by the HERE API. (Credit: Data analysis by Caitlin Myers; maps by Lucas Waldron, ProPublica)

After Hodges’ ruling, G didn’t know where to turn. She had told her friends that she was set on becoming the opposite of her mother, who had become pregnant with her — unintentionally — at 19. G grew up depending on government assistance for food and didn’t believe it would be fair to bring children into the world without financial security. She was scared of finding herself in romantic relationships like her mother’s, which sometimes led to catastrophe: G or her mother would call the cops, or the two would flee or kick the guy out. A former classmate of G’s mother, Brandi Rickert, who took them in at one point, told me that she worried about G when she was a child. Rickert could see that G wanted stability but that her mother was unable to provide it. G knew that her mother grew up in a violent home and that she was doing what she could to keep G safe. “She took hits for me,” G told me.

In G’s memory, though, her mother could turn dark in an instant. Jennifer Clark, the mother of one of G’s friends, told me that when the two briefly lived next door, she often heard G’s mother screaming, calling G “an attention whore,” “a piece of shit.” In the spring of G’s sophomore year, while she was in an online home-schooling program, G worked two jobs, including as a hostess at Razzoo’s, where she put in as many as 30 hours a week. She was expected to pay rent to her mother. (G’s mother says she never used that language or asked for G’s earnings, and she disputes G’s characterizations of her and how she parented.) That G was unusually self-sufficient, dreamy and also impulsive could put those around her off-balance. Sometimes G was a people pleaser, offering to cook or clean for Clark in a honey-sweet voice. Other times, she would shut down, refusing to talk to anyone. Occasionally, she would explode out of nowhere, throwing friendship-ending tantrums. “Well,” Clark said, “all that was learned behavior.”

Just before she became pregnant, G was finally hopeful about her future. Once she left her mother’s house, she reenrolled in high school, where the principal said that she worked harder than anyone on campus. “I didn’t know whether she wanted to be a short-order cook or a brain surgeon,” he told me, “but quite frankly, she could write her own ticket doing whatever she wanted to do.” G wasn’t yet thinking about her career. She wanted to party and celebrate her graduation, leave Copperas Cove, get an apartment of her own and comfortably support herself.

Since middle school, G identified as gay — all her relationships had been with girls, and she had envisioned building a life with another woman. Falling for Cecil had taken her by surprise. When they first got together, she recognized the ease she felt being in public with him, no longer nervous about leers or snide remarks. But she had always struggled to trust guys, and being with Cecil didn’t change that. “I still seem to keep thinking about my past, worried that it’s going to repeat itself,” she wrote in her journal. “I worry I wasn’t, won’t ever be, ready to be with a male.”

After her bypass hearing, G stopped eating and showering and responding to texts. She didn’t want people to know about her pregnancy; the few friends she told had ghosted her. “I’ve been alone my entire life, but being pregnant is an entirely other lonely cycle,” she wrote. “I don’t have drive, energy.” Her friend Shana, who was 36 and married with three children, was letting G stay in her living room on a mattress, which she had cordoned off with a bookcase and a shower curtain. Some days, Shana told me, she had to pull G out of bed and escort her to the front yard just to get some sunlight.

Shana and G on Shana’s property, where they both live

G hadn’t decided whether to challenge the judge’s ruling. She knew that Shana would respect whichever choice she made, but Shana believed that abortion was immoral, except in cases of rape or incest. She considered twins the ultimate blessing. In one outburst, which she later apologized for, Shana told G that she would be murdering two people. Cecil was no help with the decision. G thought that he was too irresponsible to offer guidance; he didn’t even clean his bedroom. Somehow the burden of figuring out what to do was falling to her, even though Cecil thought that he must have forgotten to put on a condom. G was paralyzed: She could appeal Hodges’ ruling with no certainty that it would be overturned, or she could accept the voices around her — Shana’s, the judge’s, the Christian counselor’s — that all wanted her to have the children. She had already spent weeks getting her first court date, and she couldn’t shake a sense of defeat. Overwhelmed, she decided that she wouldn’t decide. She preferred to ignore that this, too, was a decision.

After several weeks of nothing, G began to embrace her situation. She told Cecil that she was still pregnant, and they agreed that it was best to get back together to raise the twins. Knowing that she was afraid he would abandon the kids, Cecil promised that he never would. “It wouldn’t sit right with my conscience, and also, my mom would kill me,” he told me. In an effort to address her mood swings, G enrolled in counseling, telling her therapist that she worried she didn’t “even know what a healthy relationship looks like.” The pages of her journal turned to shopping lists with cost tallies: swaddling blankets, car seat head thing, breast milk bags, boobie ice packs. She started a photo album with ultrasounds and pictures of her belly. Every two weeks, Shana or Cecil drove her to the hospital in Temple, about 40 miles east, for a checkup. G’s slim frame was transforming: arms swelling, neck spasming, ankles pounding under new weight. In August, when G was five months pregnant, one of her doctors diagnosed the fetuses with syndactyly, a rare congenital condition characterized by fused fingers and toes. G wasn’t surprised; Cecil had it, and she adored his body, but she also understood that her children would need special attention.

G’s old journal, showing a list of expenses

G got a job at a day care center, which seemed like an ideal opportunity. She committed to muscle memory how to change a diaper and balance bottles to feed two infants at a time; she learned about choking hazards, the tricks to quickly mixing formula. The children’s bottomless energy, though, seemed to grate more on her than on her co-workers. The high-pitched shrieks, the sticky faces, the careless way their limbs flailed. Slowly, she realized she wasn’t irritated but envious. Without a “normal” childhood of her own, she resented the children who appeared to have one.

Eight dollars an hour was getting her nowhere, and she couldn’t handle more work on her feet. A friend told her that she could make extra money selling videos of herself on an app called Whisper. Buyers had a kink for pregnant women. At night, when Shana’s family was sleeping, she filmed herself, shielding her face with a red sequined eye mask. Cecil didn’t like it, but he couldn’t argue with her rationale. This was money she was making for their children, so they wouldn’t go without. She tried not to think about her own disgust. She had never wanted to sell her body, but soon she was bringing in as much as $400 a week. Like an actor, she imagined herself in a fictional story. “I’m a whole different character — this isn’t me.”

In November, G’s doctor recommended bed rest, advice that she took, though her employer didn’t provide paid leave. Her twins kept kicking her bladder, making her urinate spontaneously. She had gained more than 50 pounds, and she needed help just getting dressed; Shana bought her a foot-long shoehorn so that she could slip her feet into sneakers she couldn’t reach. On Dec. 9, 2020, 36 weeks into her pregnancy, G braided her long, caramel hair into pigtails, asked Shana for a final photo shoot while she held her bulging belly and drove with Cecil to the hospital to be induced. The epidural didn’t seem to work, her pain level hovering between a seven and a 10. Twenty-six hours later, G gave birth to twin girls. For what seemed like only a moment, the nurse placed them on G’s chest. They looked like wrinkly aliens. I’m supposed to be feeling something right now, she thought. She wanted a fierce, visceral love to take over, a tight grip of purpose. Instead, she felt empty.

Judicial-bypass hearings date back to a 1979 Supreme Court case, Bellotti v. Baird, in which the court declared Massachusetts’ parental-involvement law unconstitutional. The ruling rested on a previous decision that states cannot give parents “an absolute, and possibly arbitrary, veto” over a minor’s abortion. But in an unusual majority opinion, Justice Lewis F. Powell Jr. wrote that states could require parental involvement if they also allowed minors to go directly to a judge to ask for permission to end a pregnancy. He proposed that judges could be tasked with assessing whether the minor was mature enough to make the decision, though he conceded that maturity is “difficult to define, let alone determine.” A concurring opinion, written by Justice John Paul Stevens, scolded Powell for advising states on how to rewrite their laws, but legislatures began passing statutes that fell in line with Powell’s vision. The power to veto a minor’s abortion shifted from a parent to the state.

How the courts interpret maturity has since proved to be arbitrary. Judge Hodges told me that “of course it’s subjective.” He also said that part of his thinking in denying G’s petition was that he disagreed with her statement that she wouldn’t make a suitable parent. “My thought process was, You sound very mature to me, for a 17-year-old, living on your own, paying your own rent, making these decisions,” he said. “Sounded to me like she actually, probably would make a good parent.” His view was paradoxical: He believed that G was mature enough to raise two children, but he had ruled that she was not mature enough to decide if she was ready to be a mother. By law, the assessment of a teenager’s maturity should apply solely to her ability to choose whether to have an abortion — not to her ability to parent.

In Florida, for example, judges of bypass proceedings are asked to consider minors’ “overall intelligence,” “credibility and demeanor as a witness” and “emotional development and stability,” among other characteristics. In January, a 17-year-old who was planning to be a nurse was denied an abortion partly because she told the judge that her grade-point average was 2.0 and, at another point in the proceeding, said she was currently making B’s. “Clearly, a B average would not equate to a 2.0 GPA,” the judge wrote, concluding that her intelligence was below average. (An appellate court overturned the ruling, explaining that her current grades could have lifted her GPA.)

With Bellotti, the Supreme Court transformed abortion from the medical decision it was deemed to be in Roe into an act fraught with cultural meaning. If a teenager wanted to opt for a cesarean section, she didn’t need a parent’s approval — but if she wanted an abortion, she did. The state was forcing a parent’s involvement in one medical procedure but not the other. Shoshanna Ehrlich, a professor of gender studies at the University of Massachusetts, Boston, argues that it was here that the court provided one of the earliest hints that it was moving toward promoting birth over abortion. The maturity test was not about a teenager’s ability to weigh the benefits and risks of her medical choice. “If a pregnant teen on Monday says, ‘I want to be a mom,’ the teen is vested with full decision-making capacity,” Ehrlich says. “And let’s say she wakes up on Tuesday and says, ‘Wrong decision; I can’t be a mom.’ Then suddenly she is not an autonomous decision-maker. What happened between Monday and Tuesday? Did she lose her maturity?”

The Bellotti ruling came as teenage pregnancy was igniting public anxiety. The Alan Guttmacher Institute, then affiliated with the Planned Parenthood Federation of America, had released a report in 1976 that announced an “epidemic” of teenage pregnancy, a term that was quickly picked up by politicians and the news media. The discourse disregarded half the story. The teenage birth rate hit its peak that century in the 1950s, when adolescents were more likely to be engaged or married, and it was in decline by the 1970s. But the legalization of abortion had given rise to a new demographic measure, the pregnancy rate, which included births, miscarriages and abortions, and this measure for teenagers was rising. During the sexual revolution, more single women of all ages were having sex, more women were having abortions and more white women were having children without marrying. But teenagers, especially Black teenage girls, became a focus of concern.

Liberal reformers argued that teenage motherhood led to poverty, and they used the public attention to lobby for expanding reproductive health services and comprehensive sex education. Conservatives cited the Guttmacher report to try to shut down those programs. Not only did they take moral issue with sex between teenagers, but they also cast adolescent mothers as a drain on government funds. Parents, they argued, needed resources to control the sex lives of their teenage children. After the election of President Ronald Reagan in 1980, the conservative agenda prevailed.

Over the following decade, after restrictions on abortion multiplied across the country, the National Abortion Rights Action League hired consultants to shape a new campaign. Focus groups were most roused by the notion that the government’s abortion laws were interfering with the sanctity of the family, so the consultants gave NARAL a more relatable slogan: “Who Decides? You or Them?” As William Saletan describes in his book on the abortion wars, “Bearing Right,” NARAL staff members never thought the “you” in their slogan would be taken to mean parents rather than pregnant women, but the “you” was so flexible that it could refer to anyone in a family. When Democratic candidates started noticing the appeal of parental-involvement laws, many decided to support them; with NARAL’s new phrase, they could be “pro-choice” and “pro-parent” at the same time. Soon, politicians on both sides of the abortion debate — in Michigan, New Hampshire, South Carolina and Virginia — were rallying voters around mandated parental involvement. By the end of the 1990s, a majority of states had instituted the laws. About half of those states were blue.

In the weeks after G gave birth, she couldn’t summon a connection with her babies. She had moved into a bedroom in Shana’s house, and she noticed how Shana brightened while teaching the twins how to stick out their tongues. G wished that she lit up, too. When Cecil was over, he missed the goofy things G used to do, like weird dances and voices. “She didn’t really do that too much,” he told me. “She would say, ‘Stop, I’m not in the mood.’”

Pictures of G and Cecil in the girls’ room

For months, G and Cecil had been trying to find a place of their own in Copperas Cove, but without any credit history, they were poor candidates. In early 2021, they were finally approved for a big, two-bedroom Section 8 apartment, at $583 a month. Cecil was working as an overnight stocker at H-E-B and slept during the day; almost all of the parenting fell to G. At times, the babies’ giggles made her laugh, and she loved how, in the middle of their fits, if she sang opera-style, they would break out in smiles. Still, she was struck with rageful fantasies. Her primary care doctor had diagnosed her with postpartum depression, but medication wasn’t helping. Once, she found herself squeezing their fleshy bodies to stop them from crying. Sometimes, she was haunted by images of smothering them with a pillow or chucking them across the room. I shouldn’t be alone with these kids, she thought. I’m an unstable mother. She couldn’t tell anyone, and she was doing her best to control her anger. If Child Protective Services were called, she worried that her girls might be placed with someone who could not restrain herself. “You have to live with these fantasies,” she told me. “You’re told to shut up and deal with it.”

Although G had applied for Temporary Assistance for Needy Families, the safety net program for low-income parents, she was denied because their household income exceeded the $231 monthly threshold. Cecil covered the rent, fast food, utilities and their car payments, but G wanted an income of her own. Rachel and Michael Borego, the parents of a friend, offered to watch the babies at their home on the weekends, allowing G to get a job as a waitress. G kept asking Cecil to help clean, at least wash his own dishes. He complained about his exhaustion and her nagging; he felt that he had lost his dream to build a streetwear brand and that he couldn’t meet the impossible expectations of fatherhood. “I feel like a single mother already,” G wrote to Cecil in a letter. “I love you for just being there, holding me and giving me a slice of peace that I didn’t think existed, but I’m not happy.”

That spring, G found herself stuck on TikTok, addicted to videos about “the simulation theory” — a conspiracy that we’re all living in a kind of Matrix. G felt so cratered by her own powerlessness that the world around her had stopped feeling real. Even her ties to her former self were slipping away, she wrote in her journal. “I used to have fire in my eyes, I used to be the strongest fighter I know.” Now it seemed that her discipline, her ability to hustle for the future, was pointless. Cecil wished he knew how to give her motivation.

In September, G and Cecil broke up, but because G couldn’t afford to leave, she moved into the closet in the girls’ bedroom, sleeping on a mattress next to diapers. She watched herself slipping into behaviors she had seen in her mother: the bouts of anger, the deep retreats. “I’m trying to get me back,” she wrote. “I want to be bubbly, outgoing again.” Shortly after, G moved into the Boregos’ red brick home with the twins. She got a job at a call center, making $480 a week. The average cost of child care for one infant in Texas is about $190 a week; she couldn’t afford to send two. Instead, G and Cecil split the cost of a babysitter. Rachel, who worked in accounts payable, and Michael, a technician for AT&T, bought the girls clothes and books and toys.

For months, G had been doing her best to push down suicidal thoughts, but now they were coming back stronger and more frequently. “I know that my kids need me, but I need to be done.” After she drafted a goodbye letter to her girls and slipped it behind a framed sonogram, she knew she needed help. Rachel agreed to take care of the babies if G signed a power of attorney. On Nov. 11, 2021, a month shy of the twins’ first birthday, G checked herself into Canyon Creek Behavioral Health, a nearby psychiatric hospital.

At Canyon Creek, the sterile rooms were quiet and still. G talked with a doctor about her mother, whom she called her “birth giver,” and when she discussed her children, she agonized over not having “the mom gene.” A doctor diagnosed her with major depressive disorder and post-traumatic stress disorder, prescribing new medications. “I miss my girls,” she wrote. “Not the crying lol. But I miss their smiles, I miss their sweet hugs & when they lay their heads down (on me).” She was there, she reminded herself, so the twins could have a strong role model, but the shame of leaving, of taking time for herself, wouldn’t go away. “I feel like I’m hurting the girls by doing this, disappearing,” she wrote. “I feel like all I do is hurt them.”

Later that month, when G returned to the Boregos’ house, Rachel began to wonder if G wanted to be a mother. For G, it was no longer that simple. To prepare for Christmas, she had started working four jobs: taking orders at McDonald’s, cleaning the kitchen at Monty’s BBQ, delivering for DoorDash and selling plasma for extra cash. Even then, she wasn’t earning what she needed to raise her girls on her own; Cecil’s work schedule allowed him to take them only two days a week. In the thick of that stress, when she worried that her girls were absorbing her negativity, she hid in her bedroom to protect them from it.

In February, Rachel and Michael approached G with an idea. They could tell that she wasn’t happy, and they were willing to take care of the girls for six months if G wanted space to get her life on a steadier path. They could settle on a more permanent arrangement after that. They had fallen in love with the girls, they said, and if G wanted to relinquish custody, they would try to adopt them right away.

Despite G’s fear that the Boregos wanted to take the twins from her, she couldn’t deny that she felt relief. “I’m not ready to give the girls up,” G told the Boregos. She usually speaks with a flat affect, but Rachel noticed her eyes tearing up. She wanted to move out for a trial. She packed her bags and left that night.

G working a delivery shift at Papa Johns

Whenever G’s friends asked how she was doing, she was torn between the desire to say the truth — that she was angry at herself, the government that made her have children, the expectation that she would love being a mother — and the similarly strong desire to deflect, so she wouldn’t be seen as a bad mom. The times she tried to talk about her frustration, she knew she elicited disdain, as if she had done this to herself. Almost no one showed her sympathy for being a single teenage mother.

Self-destructive, dependent on the state, doomed to failure — those are the stereotypes that have come to characterize teenage mothers since the moral panic of the 1970s. But what both liberals and conservatives miss in their legislative efforts is the research that has left a growing group of sociologists, demographers and economists with a different conclusion about the relationship between early childbearing and poverty. Frank Furstenberg, an emeritus professor at the University of Pennsylvania, ran a three-decade-long study on teenage mothers, beginning in the mid-1960s; his first substantive results, which came in during the 1970s, challenged widely held assumptions, even his own. A great majority of youths who become pregnant are, like G, already living in low-income neighborhoods with underperforming schools and low-wage job prospects. The consequences ascribed to teenage mothers are not so much a function of becoming pregnant as they are a function of growing up in poverty. Teenage motherhood isn’t the root cause but rather an indicator.

Since the 1990s, the teenage pregnancy rate has declined drastically — more than 70% — in part because of less sex among youths and increased use of quality birth control. With the new combination of the Dobbs decision and entrenched parental-involvement laws, though, many social scientists expect that, for teenagers who do become pregnant, the birth rate will rise again soon. By and large, these mothers will be adolescents, like G, who grew up poor. What policymakers and researchers have not yet studied are the financial and psychological consequences of parental-involvement laws that force these teenagers into early motherhood.

Today many states that legally defend the right to an abortion for adults still limit that right for teenagers. Maryland enforces a soft version of parental notification, allowing physicians, rather than judges, to determine if a minor is mature enough to make this choice or if an abortion is in their best interest. But Colorado, Michigan, New Hampshire, Pennsylvania and Rhode Island all enforce standard parental-involvement laws. In some, legal networks have sprung up to help guide teenagers through the judicial-bypass process. The Women’s Law Project, which provides representation in Allegheny County in Pennsylvania, receives about two calls a week for help with hearings across the state, but Sophia Elliot, one of its staff attorneys, told me that there aren’t enough trained lawyers in most counties to meet the need. It’s not clear that all the teenagers who are looking for help ever find her organization. “There is always a question of, Who are we not seeing?” she told me. “Oftentimes, the failures in this system are silent.”

As the Supreme Court has shifted to the right in recent years, states have begun to diverge on parental-involvement laws. A few have tightened their restrictions — switching from laws that require parental notification to those that require consent, or mandating that teenagers file petitions in their home counties rather than in more progressive cities, or demanding that minors show “clear and convincing evidence” of their maturity, rather than a “preponderance of evidence.” But three states have liberalized their restrictions. Last year, Illinois repealed its parental-notification law. This summer, a Minnesota District Court judge ruled that the state law that required both parents be notified of their child’s abortion decision violated the state constitution. In Massachusetts in 2020, advocates including the state’s NARAL affiliate at the time tried to eliminate the law there. Although their effort fell short of a full repeal, Massachusetts did change its statute so that it now applies only to those who are 15 and younger.

Elizabeth Janiak, an assistant professor at Harvard Medical School whose research on the Massachusetts law helped inform the Legislature, told me that even changing the statute was politically challenging. Parental-involvement laws, she now believes, will not go away any time soon, even in firmly blue states. “From what we saw here in Massachusetts, and how sensitive this law was for legislators, it wouldn’t surprise me if these abortion restrictions were the last to go.”

G in her loft bed in November

When I visited G in May, she was living on Shana’s property in a one-bedroom camper, which the Boregos helped her buy. She was calmer than I had ever seen her, more focused. Twinkle lights dangled from the ceiling, and scented candles lined her dresser. The camper had no water yet, so G used the bushes as her bathroom, and because the roof leaked when it rained, she had lined the floor with towels.

We went outside, where G sat on a swing under the canopy of an oak tree. She wasn’t sure what to do. G didn’t have room for the girls in her RV. She had 83 cents in her bank account, and if her children were with her, she wouldn’t be able to feed or even bathe them. There was no way that she could give them what the Boregos could: a big house, their own bedroom, routine affection. She was waiting for a pro bono lawyer to answer her questions about possibly giving guardianship rights to the Boregos. She was scared that if she did, she might lose the girls forever, that she would regret this down the line, the same way she now regretted continuing her pregnancy. She would also have to talk with Cecil, who still cared for the girls two or three days a week and could petition the court for full rights. He’s capable of being more involved, so is he the better parent? she wondered. She was ashamed, she said. She was still doubting her ability to do the one thing her mother did do: keep her child. “I was never ready for this, and I knew that,” she said. “I tried telling people, and they didn’t listen.”

Her six-month trial with the Boregos ended in August, but G still wasn’t prepared to make a decision. Instead, she extended the trial, signing a new power of attorney. The Boregos have moved to a larger house, 30 minutes away, and every few weeks, G visits her children, though it’s painful to see them. When she walks through the door, the girls no longer run up to hug her. Their distance stings, but she knows that it stems from her absence. She keeps missing more firsts, she told me: their first steps, their first sentences, the first time one of them asked, “What’s up?”

Several weeks ago, G texted me in the middle of the night, worried: She could give up her parental rights, as her father did, or she could raise her children without the stability or the warmth that they deserve, as her mother did. In her own experience, both left her feeling abandoned, unloved. She didn’t know which one was worse.

G, with the twins and Rachel and Michael Borego

Are You in a State That Banned Abortion? Tell Us How Changes in Medical Care Impact You.

Doris Burke contributed research.

by Lizzie Presser, photography by Parker Hill and Isabel Bethencourt for The New York Times

Marlene Terry

2 years 7 months ago
State Rep. Marlene Terry is the latest guest on Politically Speaking. The Democrat from Bellefontaine Neighbors talked about her pathway to the Missouri House and her goals as chairwoman of the Missouri Legislative Black Caucus.