Anita Rao
You know many someones who've had an abortion. Their reason? Depends. Maybe a kid in that moment would have meant not being able to pursue their dream of becoming a social worker. Maybe it would have sent them into severe financial distress. Maybe they already had two other kids and the timing just wasn't right. None of these scenarios is hypothetical. They're all real people I know, and the last example is my own parents.
Dr. Satish Rao
The timing was- was going to make it extraordinarily challenging for us, the time we were in. And so, we thought the right thing was to proceed in this fashion.
Anita Rao
Were there any, like, conversations that you all had after? Did you ever have any mixed feelings? Or it was it very much, like, we know this is — we knew this was the right decision at the beginning. We felt that way the whole time. We always continue to feel that way.
Sheila Rao
100% completely, no regrets at all. No conversations, no, nothing. Just very, you know, matter of fact, this is what's happening. And after the procedure was over, didn't — really never talked about it again, literally. Literally never talked about it again.
Anita Rao
That's a conversation I had with my mom and dad about their own abortion story last year. Studies show that just like my mom, the vast majority of folks who get an abortion — like 90-some percent — don't regret it. As of Friday, June 24, access to abortion in this country is more limited than it's been in my entire lifetime. The thoughts burning in my mind are many, but at the forefront is this one: People are not going to stop getting abortions. It's just going to become far more difficult to do so safely.
Anita Rao
This is Embodied. I'm Anita Rao. There are still many unanswered questions, pending legal action and ongoing analysis. But for now, one thing is a given: North Carolina will be one of the few places in the American South without an abortion ban in place. This state will become the nearest safe provider for millions of people. Back in 2020, in light of the Supreme Court appointment of Amy Coney Barrett, I spoke with a family physician in North Carolina about the appointment's significance. Her name is Dr. Rathika Nimalendran. She works at Planned Parenthood South Atlantic and is also a fellow at Physicians for Reproductive Health. With the news about the reversal of Roe vs. Wade, we wanted to check back in with her and hear about what life is like on the ground. Turns out, it's even busier than I could have imagined. Right before we pressed record, she told me she just had a baby.
Oh, wow. Are you — how far out are you from, like, how...
Dr. Rathika Nimalendran
Well, my baby came two months early. So, he's seven and a half weeks, but his due date was yesterday.
Anita Rao
Oh my gosh, oh my gosh, well triple thank you for making time. I'm sure you're very sleep-deprived.
Dr. Rathika Nimalendran
A little bit. I tried to take a little nap before that so I could be coherent.
Anita Rao
So yeah, she's been busy. But, she and others providing abortion care around the state have also been preparing for this moment.
Dr. Rathika Nimalendran
The Supreme Court decision was not unexpected. I think there was a lot of pre-determinating changes across states, across the Supreme Court, that made this seem almost inevitable for many of us who work in abortion care. So, while we were planning for Roe to be overturned, we were all devastated. We are all devastated, because we working on the ground see our patients and see exactly what they're going through. And also, we just know that abortion is a part of safe and normal health care.
Anita Rao
Rathika and providers like her around the state have been aware that the overturn of Roe would likely lead to North Carolina getting a big influx of new patients. The organization that she's a part of, Planned Parenthood South Atlantic, has increased support and patient navigation services. Another provider with locations around the state called A Woman's Choice, told a local North Carolina news outlet that they've made plans to expand hours, hire new staff, and even partner with hotels so that folks have lodging. There's a lot to get into with Rathika. Before we dive into this full conversation, I just want to make a quick note that this podcast may sound a little different, because well, the world is a little different. And, we wanted to get it out to you in as timely a way as possible. Alright, let's get into it.
Dr. Rathika Nimalendran
You know, I've been providing abortion care for a few years in North Carolina. And, throughout that time, I have cared for many patients that are coming from out of state; from South Carolina, Tennessee, West Virginia, Virginia, even Georgia. And, that is because over the last few years — you know, really for the last decade — we've seen this exponential increase in abortion restrictions across the states. And, especially across states held by Republican governors and legislators. So to say that, you know, are patients gonna be coming from out of state? Yes. It's that they have already been coming from out of states because these restrictions have already made it difficult for patients to access that care near home.
Even in North Carolina, we have to remember that 91 out of 100 counties do not have an abortion provider or provider can provide that care, just in North Carolina. So, even our North Carolina folks are often having to travel several hours to access care. When we increase the numbers that we're likely going to be seeing, that means we have to increase capacity. But even before that, patients had to wait weeks to get an appointment. I saw patients who said, "You know, I came to North Carolina from four or five hours away, because it was the soonest I could get an appointment. It was going to be a month out otherwise, if I went somewhere closer, which was still going to be one to two hours away."
Anita Rao
So, you mentioned only nine counties that offer some form of abortion services in the state. And, there are restrictions, even where it is offered. Lay out some of the restrictions in North Carolina.
Dr. Rathika Nimalendran
Of course, and North Carolina does have some pretty strict restrictions. The first that is, I think, really important is the 72 hour mandatory wait. And during this, a patient has to get consented for an abortion, whether it's medication or procedural. And essentially, they're forced to listen to a script provided by the state that provides non-medically accurate and, just, untrue information. They then have to wait at least 72 hours before they can get their abortion, and sometimes that means if they're in clinic, we have to make sure that the timing is correct. And, I might have to wait to give them that one medication abortion pill until it's been at least 72 hours. So, that is a huge restriction. It affects, you know, what form of abortion a patient might get because it delays care.
Additionally, you know, I know a lot of people are really interested in telehealth for abortion. Unfortunately, for many years now, North Carolina has had a ban on telehealth for abortion care. There are what we call TRAP restrictions, or essentially targeted restrictions on abortion providers, that make it very difficult for providers to provide abortions in North Carolina — even for providing a medication abortion, which is two medications mifepristone and misoprostol, which is exactly the same medications that I use for miscarriage management. We're expected to essentially be providing this care in a surgery center given these, like, unnecessary restrictions that have been legislated in North Carolina.
There's legislation so that if you are a minor, if you're under 18, you either have to get parental consent or a judicial waiver, which can be very difficult for a young person to obtain.
Anita Rao
Yeah, I want to talk with you more about the medication abortion later on in the conversation because I know that's been a big part of the discussion in the overturn of Roe v. Wade. But I want to talk about one more thing before we do that, which is that there was a North Carolina law that banned abortions after 20 weeks that was deemed unconstitutional in 2019. But now, some North Carolina Republican legislators are calling on the Attorney General to reinstate that 20 week ban. As of the time that you and I are talking, the Attorney General's office has not yet responded, but evidence does suggest that it's likely the 20 week ban will be reinstated. So, I'm curious about the significance of this ban. Who does it most affect?
Dr. Rathika Nimalendran
So the 20 week ban was enjoined, I believe, one or two years ago. You know, like I said, abortion is safe and normal health care. Most late second trimester or second trimester terminations are not very common. They are quite rare. And, they may be because someone is unable to access abortion care. They may not have known they were pregnant earlier, or it may be for fetal anomalies or maternal health. Those are all normal reasons to get an abortion.
If the 20 week ban is reinstated, what we will find is that patients are going to — who need that care are either not going to be able to get that, which could put their life in jeopardy, it could put their family in jeopardy, and if they have the resources available, they're going to have to go out of state. And, with the number of states that are having significant restrictions, that's going to put a burden on the the areas that can provide that care.
Anita Rao
20 weeks might sound late to a lot of people, but when you look at markers that happen along the pregnancy timeline, why is the 20 week mark significant? Why would someone not know until 20 weeks that something might be wrong with the fetus?
Dr. Rathika Nimalendran
Well, first of all, it's not significant in terms of, like, why it was- it's not medically significant. Let's remember that the legislation is done by politicians and not doctors. In terms of why it would be significant for patients, however, if this is a desired pregnancy, that's about the time that you get an anatomy scan, which may show various fetal anomalies. I actually remember my own provider — I recently had a baby — say, "You know, I want to make sure that we can get — I try to get my patients scheduled for their anatomy scan just by 20 weeks to make sure, in case they do have to unfortunately terminate the pregnancy that they would have able to access that care." Because even though that 20 week ban was enjoined, many providers are unaware of that. So it's really, really — the shifting legal landscape, even within North Carolina, is so difficult to parse. And, many doctors, even OBGYNs, are not aware of the restrictions and the changing landscape.
Anita Rao
Figuring out how to make sense of the changing legal landscape while also doing your job day to day — not easy. And as Rathika mentioned, not new. State level abortion measures restricting access have been increasing for years. In fact, 2021 marked the highest number of new abortion restrictions passed into law in a single year. Those who will be hit hardest by these new bans are those who are already the most marginalized. What this moment has brought up in particular for y'all was a big question on our minds this week. So we asked, and this is what you told us. First up, one of our recent Embodied guests, Leona Godin, then you'll hear from our friend and former colleague Stacia Brown.
Leona Godin
I think I'm most concerned about the fact that I've seen a lot of reluctance in social media to tell our own personal stories. And, I think that that's out of a sense of shame, and that shame doesn't necessarily go with our politics. For my own part, I've done a lot of things in my life that I regret, but having an abortion is not one of them. I was not ready to be a parent, and I will never be sorry that I did not bring an unwanted life into this world. I feel so sorry for the young women of today and tomorrow. I wonder if we would have spoken out and told our stories leading up to this decision, if older women would have talked about the fact that they had gotten an abortion in their youth — I wonder how that might have affected this terrible decision.
Stacia Brown
The thing I'm most concerned about in this moment is my daughter's future. She'll be 12 in a few weeks, and we've been talking openly about sex and contraception for at least three years now. We talked about birth control pills, we talked about IUDs., we talked about condoms, we talked about abortion. And now, that is not as accessible an option as it would have been to her when we first had that conversation. And, I'm really not sure how accessible that will be to her in years to come.
I hope, as most parents, that she never finds herself in over her head or caught unaware or facing the unimaginable. Because if she is, the way forward for her is much muddier now than it's ever been in my lifetime. I'm concerned about how to update her on the loss of her federal right to safe healthcare. I'm concerned about how to prepare her for the many fights for equity that will lay ahead for her as a Black young woman in this country.
Anita Rao
That was Leona and Stacia. Leona is a performer, educator and the author of "There Plant Eyes: A Personal and Cultural History of Blindness." Stacia Brown is a creator and writer living in North Carolina.
For Rathika, this moment has also meant some extra awareness of conversations around the criminalization of providers. In some of the states in which abortion is already banned, abortion providers will be charged with a felony, some with penalties of up to 10 years in prison and steep fines. That's not the case in North Carolina, but without a federal protection in place, everything is subject to change.
Dr. Rathika Nimalendran
Of course, it's extremely scary. I think the first thing is that, we will provide safe and compassionate care to our patients within the confines of the law. And, that's the part that's really, really hard. If I'm unable — I mean, I'm already unable to provide the medical care that I am trained and knowledgeable and certified to provide because of political legislation. And, when we criminalize providers, that decreases the amount of providers who are able to provide abortion care. But also, as we've already seen, there are clinics across the country that when the Supreme Court decision came down, the governor — within minutes, I think, in South Carolina, or in other states — were already imposing pre-Roe laws or trigger bans. And, that meant that patients who were actively in the clinic or had an appointment that day had to be called and told that we couldn't provide that care, because we really have to make sure that we keep our providers safe, so they can continue to provide this care. And, I think that's really devastating, as many clinics have stopped across the nation, because it's unclear what the trigger bans and the pre-Roe bans truly mean, in this moment. And, the legal ramifications and, just, parsing out those legal parts to the care is really scary. And, it's frustrating and angering for us to have to deny care. I think that's the biggest thing.
Anita Rao
And I mean, it brings up the fact that there is, there is nuance in the way that reproductive health care looks like. But also, there are things like, the procedure to treat a miscarriage is similar to that used to terminate an otherwise viable pregnancy
Dr. Rathika Nimalendran
It's actually the exact same.
Anita Rao
The exact same, okay, so I mean, how...
Dr. Rathika Nimalendran
I mean, if I have a patient who comes in, and we find out that actually her pregnancy is not viable — she's, you know, had a miscarriage, but the pregnancy is still in her uterus — I offer her the exact same options. It's just that I might be able to get her insurance to cover it.
Anita Rao
So, how do these abortion bans limit the kind of care doctors are able to provide to patients who are pregnant and maybe miscarrying? Do they have an effect?
Dr. Rathika Nimalendran
I mean, I think that's probably what's already happening. If a doctor is unsure — I mean, I'm a doctor, I'm not a lawyer. You know, I didn't go to law school and even lawyers, like, they need time to figure out exactly what the laws mean in every circumstance. So it means that it might delay care, that means a person could be hemorrhaging, but, because there's still a fetal heartbeat, they're unable to get the care they need, because their provider or the hospital or the clinic is concerned about how it might criminalize their providers or even the patient.
Anita Rao
I want to talk about how people are still going to continue getting abortions. They were getting abortions before Roe v. Wade, they are going to be accessing abortions now. It's just going to look different. What conversations have you been a part of about looking out for and supporting the health of people who are looking for alternative means to get an abortion, whether that be online access to pills, whether that be something else?
Dr. Rathika Nimalendran
So self-managed abortion is something that, I think, for many people sounds really new, and they haven't heard about it. In the abortion world and in abortion advocacy, you know, we have been talking about this for some time. If you think about it, in many countries — including the country my family is from, Sri Lanka — abortion is illegal. And people have been utilizing self-managed abortion and programs like Aid Access, which mail the abortion pill, mifepristone and misoprostol for years, and we do know that self-managed abortion is safe. However, patients shouldn't be forced into having to self manage an abortion. You know, they should be able to go to their doctor, get the care that they need and the support that they need to manage their abortion. And then, there is concern of criminalization of people who self-manage their abortion. We already have so many cases, sadly, of people of color in Indiana, where people were criminalized for self-managed abortion or the possibility of a self-managed abortion.
Anita Rao
I want to talk about access a little bit more. So, the ability to go online and research and then purchase something requires money — could cost hundreds of dollars. That's not doable for everyone. There was this big landmark study in 2016 that examined the economic impact of being denied an abortion, and determined that women who are surveyed were four times as likely to be living in poverty after being denied an abortion. So, being forced to have a baby has economic consequences, the ability to access an abortion requires economic means. So talk to me a bit about how you see this economic disparity show up in the kinds of patients that you're serving.
Dr. Rathika Nimalendran
So, you're exactly right. I think what many people have said is that overturning Roe is something that is now affecting everyone who has the ability to become pregnant. But really, the lack of access to Medicaid, lack of expansion of Medicaid, chronic, you know, poverty, chronic lack of access to food — all of those that affect healthcare, and especially affect marginalized populations. Your populations that are Black and brown, immigrant, rural and queer especially, are the populations that were already being affected and unable to access abortion care. The people who were already losing out on economic opportunities and already in poverty, because they couldn't access an abortion or pay for an abortion, whether that's because the the clinic was too far away or they didn't have the money to be able to afford it. So what we're seeing now is that there's kind of an uproar because Roe is overturned, but the lack of access to abortion has been a huge problem for many people in our country who were already struggling.
Anita Rao
Research has also shown that Black mothers are two to three times more likely to die from pregnancy related causes than white mothers. I'm curious about your thoughts on maternal mortality rates for Black woman with more abortion restrictions.
Dr. Rathika Nimalendran
I think that that is just going to continue to worsen. I think with abortion restrictions, we already are seeing worse outcomes for maternal mortality, especially in our Black moms. Again, that we're going to see lack of access to care, because patients may be afraid to come in if they are pregnant, they may not be able to access maternal care. And, I know in North Carolina, for my patients who are, you know, undocumented immigrants, their access to maternal health care is lower, because they often don't have Medicaid for the entire pregnancy, which really limits their ability to afford and access care. All of those play into infant and maternal and family outcomes. And when a patient can't access an abortion that they wanted to, we see just these really long, long lasting generational outcomes and harms.
Anita Rao
I want to talk a bit about, yeah, a bit about this moment of, I mean, heavy emotion and emotion driving action. I saw reports this morning on the Wall Street Journal that people are, kind of, running to CVS and Walmart to purchase Plan B. And, there's this huge surge in demand, and there is a ton of fear and some confusion about the differences between all of the things along the contraceptive journey. So, I just want to clear up one thing with you: the distinction between the abortion pill and Plan B, and the major differences you want to make sure people aren't confused by, in terms of access and efficacy of these two things.
Dr. Rathika Nimalendran
Definitely. Emergency contraception, which — of which there are several kinds — just, is not an abortion pill. So, the abortion medications that we use are either misoprotsol alone in some, you know, some countries, or mifepristone plus misoprostol. Other options are Ella, which is ulipristal, and Plan B, which is a progesterone. Ella is — I know, we do offer it at our Planned Parenthood.
Plan B is the one that's most well known, it's available over the counter in most states. It's about $50 if you don't have insurance. If you have Medicaid and get a prescription from your provider or any other — most other insurances, you can actually get it for free. It's not perfect, and you do need to take it within a certain amount of time — the soonest as possible — but it works by delaying ovulation. So it does not cause an abortion. It just kind of pushes your ovulation a few days later to prevent fertilization.
However, you know, there are some things I think it's really important for people to know about Plan B. You know, studies have shown that it is not as effective in people with higher BMIs. And, it is still important to confirm that you are not pregnant because again, if you've already ovulated, it won't prevent fertilization if it's already happened. So I always encourage, if you are needing to take Plan B to, you know, check in with your provider and make sure that you have it. You know, when I do prescribe birth control — when I see patients for contraception, I will often give them a prescription for Plan B to have on hand and often say, "You know, have one on hand just in case. If in that moment, you're not scrambling to try to find how you can get it." So, but I don't encourage people to go out and buy tons of Plan B. And also, to make sure it is the appropriate emergency contraception for you.
Anita Rao
Of course yeah, there's a lot of necessary distinctions as you mentioned. Yeah, may not work for people over 155 pounds, not likely to work for over 195 pounds. So, a lot of important distinctions to keep in mind. As we close out, I want to talk about looking forward. The political climate in North Carolina is going to be in flux. GOP state leaders have spoken out about intentions to introduce new restrictions next year. There are elections this fall, abortion is going to be a hot political topic here. When you, as a provider, see these political arguments about abortion playing out, what is it that you wish folks could hear from a provider like you, who is providing this care day in and day out?
Dr. Rathika Nimalendran
Wherever you are on your thoughts of abortion, I think that many people don't realize, just, that the patients I see are, are you and me and everyone around us. They're just making a decision for their own self. And, it's thoughtful — no one is making a decision, just you know, on a whim, like you might go get ice cream. And, we really need to actually continue to lose many of the restrictions that are already in place, because they are such huge barriers to North Carolinians. And as I said before, like, we're already seeing the ramifications of these restrictions, and the long term harms that they have on families, on mothers and on children — in terms of health care, in terms of long term economic prospects.
Anita Rao
I want to close with reflecting on the first time we talked with you. It was in the fall of 2020, and you told us about being raised by a mom who told you about the experiences of people she knew growing up in Sri Lanka who had to undergo illegal abortions and unsafe conditions. I don't know if your mom is still around — if you and she are talking about this topic — but I'm just curious about how you're reflecting on those stories and that experience in this moment.
Dr. Rathika Nimalendran
I'm so proud of my mom and, just, the openness as a South Asian immigrant with which she has discussed these difficult topics. Since then, you know, I've had other people talk to me about their experiences with abortion. And, again, like you mentioned with your parents, that there was no regret, that it was the right thing to do. However, knowing these experiences, knowing what it's like for people in Sri Lanka to have to obtain an abortion, you know, I don't want anyone to have to go through struggling to find that care, or not being able to get safe care. So, it continues to haunt me hearing those stories, but I really just hope that here in the U.S., we can change this course. It's not just abortion care for me. It just — seeing how healthcare is politicized and seeing how my patients are affected, it's heartbreaking to me to not be able to provide the care that I know I can provide because of these limitations and restrictions.
Anita Rao
Dr. Rathika Nimalendran is a family physician at Planned Parenthood South Atlantic and a fellow at Physicians for Reproductive Health. I know that y'all have been inundated with this news, and I have too. It has been a whole lot, but we're gonna keep talking about it and processing it together. If you have stories, questions or perspectives you want to share with us, we want to hear them. We have a virtual mailbox called SpeakPipe, and you can leave us a message there about anything. You can find a link on the right hand sidebar of our website embodiedwunc.org.
Embodied is a production of North Carolina Public Radio-WUNC, a listener-supported station. If you want to lend your support to this podcast and WUNC's other shows on demand, consider a contribution at wunc.org now. Incredible storytelling like you hear on Embodied is only possible because of listeners like you.
This episode was produced by Kaia Findlay, Amanda Magnus is our editor, Jenni Lawson is our sound engineer and Quilla wrote our theme music. If you enjoyed this show, leave us a star rating or review on Apple Podcasts or Spotify or whatever platform you listen to. It really helps new folks find our show. Thanks so much to Leona and Stacia for sharing their thoughts with us.
Until next time, I'm Anita Rao taking on the taboo with you.