ON JUNE 24, THE DAY THAT THE SUPREME COURT DECISION REVERSED THE LANDMARK DECISION ROE V. WADE that legalized abortion in the U.S. nearly 50 years ago, activist Esther Hobbs experienced a visceral physical reaction, and an emotional one that reverberated to her core.
“When that moment came, I was actually physically ill and I cried for about 10 minutes solid,” says Hobbs, leader of Women’s March Monterey Bay. “Then I said, ‘This isn’t going to go down without a fight.’”
That urge to fight manifested several hours later as Hobbs, along with about 200 people, were at Window on the Bay in Monterey hoisting protest signs into the air and chanting slogans like “abort the court” and “my body, my choice.” Hobbs saw young people at the march she had known almost their entire lives. “I was devastated that the landscape in America now looked like they had lost their rights,” she says. “They understood all the ways their rights had been diminished that day.”
While the decision that overturned Roe – Dobbs v. Jackson Women’s Health Organization – took away a fundamental right to privacy that protected reproductive rights even in Republican-led states with leadership hostile to abortion, Californians were already enjoying protections that keep abortion legal in the state. The state cemented its role as a beacon of refuge for people from states where abortion had already been severely restricted.
Gov. Gavin Newsom declared California a “Reproductive Freedom State” by proclamation in 2019, amid a backdrop of attacks on abortion access in other states. At that time, the Dobbs case was on its legal journey from Mississippi to the U.S. Supreme Court.
Abortion providers like Planned Parenthood Mar Monte (PPMM), which serves Monterey County, saw that Roe could be in trouble. They started preparing for what they predicted would be a wave of people coming to California once abortion was made illegal in their states.
The preparations proved prescient and necessary: Immediately after the Dobbs decision in June, PPMM saw its out-of-state abortion patients quadruple in July and August compared to the same period last year, according to Dianna Zamora-Marroquin, a PPMM spokesperson. Their total number of out-of-state patients was greater in those two months than in all of fiscal year 2021-2022, which ended on June 30. Since the beginning of fiscal year 2022-23, July 1 to Nov. 29, the nonprofit has seen a 290-percent increase in patients seeking abortions from out of state.
The landscape of abortion in California has changed dramatically, and it’s not done changing yet. Starting Jan. 1, California’s public university health centers, including the one at CSU Monterey Bay, will begin providing abortion medications thanks to Senate Bill 24, passed by the California Legislature in 2019. In the coming year, a slate of pro-abortion legislation will take effect, further cementing California as a beacon of access.
Voters in California are behind these efforts: On Nov. 8 they passed Proposition 1 by a large margin – 67-33 percent statewide; in Monterey County, 71 percent of voters said yes to Prop. 1. It enshrines the right to choose in the California Constitution.
Women have been making the choice of whether or not to carry a pregnancy to term throughout human history. There are references to abortion methods such as herbs, probes and others in writings as early as 1550 BCE, and in multiple cultures. Not all methods were safe and not all were successful. Abortion was regularly practiced in Colonial America, usually using herbs or medications, as mentioned in medical journals and advertised in newspapers in the late 1700s and early 1800s.
THERE WEREN’T NECESSARILY LEGAL LIMITATIONS OR PENALTIES IN EARLY TIMES. Laws began showing up in some colonizing European countries around the 1600s. By the end of the 19th century, nearly every country in the world had some legal restrictions, as chronicled in a 2017 article in Health and Human Rights Journal. The reasons for laws regulating abortion included preventing abortionists from killing women using unsafe practices, deterring abortions for moral reasons and protecting fetal life.
It’s that combination of risk, moral judgment and illegality that led to shrouding the procedure in misconceptions and misunderstandings. Substantial research shows today’s abortions are safe – so safe that they are considered safer than carrying any pregnancy to term. A study in 2012 comparing abortions to live births in the U.S. between 1998 and 2005 found that abortion was 14 times safer than childbirth, with 8.8 women dying while giving birth per 100,000 live births. Only 0.6 deaths were reported per 100,000 abortions.
Underestimating the safety of abortion is one of the most common misunderstandings patients at Planned Parenthood Mar Monte share with Jessica Dieseldorff, a nurse practitioner and program manager of abortion services. Patients worry they might be harmed or that their ability to conceive later in life may be negatively impacted. “It’s really striking to me throughout my career,” she says.
Dieseldorff has been providing abortion services since 1998, starting with assisting physicians. She was able to prescribe abortion medications beginning in 2003, three years after they were first made available in the U.S.
Beginning in 2009, she was performing the surgical procedure herself as part of a multi-year study by Planned Parenthood and UC San Francisco that examined whether it could be performed safely by NPs trained in the procedure. The study confirmed it was safe, and the state allowed the practice starting in 2014.
Patients also worry they will be treated harshly by clinic staff and abortion providers, Dieseldorff says. “It’s an experience I have over and over: patients being surprised at how caring the staff and abortion providers are,” she says. “People don’t understand the fact that abortion providers love the work that we do. I find it really meaningful to support patients during what can be a crisis period in their life… it’s really my honor to be able to take care of patients during that time.”
Ultimately, Dieseldorff says, abortion is an important part of health care and must be preserved for the well-being of patients.
“Having a child is a big decision and a big responsibility and a major life change,” she says. “Being able to have control over your body and make your own decision of when to have a child and under what circumstance, being the best parent you can be… these are basic to someone’s physical, emotional and spiritual health. Thats why abortion is a really powerful part of basic health care and preventive medicine.”
THERE ARE ONLY TWO CLINICS IN MONTEREY COUNTY WHERE ABORTIONS ARE PERFORMED, both run by PPMM, located in Salinas and Seaside. Accessing abortion services starts with making an appointment.
“It’s really similar to many other doctor’s visits,” Dieseldorff says. During the visit, simple tests are performed to make sure the procedure is safe for the patient.
Next, the provider will do an ultrasound to determine how many weeks along the pregnancy is. There is no requirement for a patient to look at the ultrasound, unlike in six states that require providers share the image – a coercive tactic in hopes of deterring someone from going through with the abortion.
“Ultrasound experts agree that it’s not medically appropriate to share an ultrasound image” if the patient doesn’t want to see it, Dieseldorff says. (A 2017 study of the impact of a Wisconsin law requiring viewing showed it had little overall effect. Most women had already made up their mind.)
“We ask them before we start how much information they want to know about what we’re seeing on the screen,” Dieseldorff says. Some people are curious and want to look, others find it helpful to understand what’s happening. It’s common for patients to feel sadness while doing so, but every person’s experience is different, she says.
PPMM providers are able to perform surgical abortions up to 19 weeks and six days, which is a little more than five weeks into the second trimester – but it’s not common. Most abortions at PPMM take place within the first 10-12 weeks. (The first trimester ends at the 13-week mark.) For abortions up to 14-16 weeks, a gentle suction procedure is used that takes several minutes. After that, providers may opt for a dilation and evacuation procedure that uses both suction and medical tools. (Anything after 19 weeks and six days, patients are referred to hospitals that perform the surgery.)
Aftercare for in-clinic abortions are rarely needed, Dieseldorff says.
Patients less than 10 weeks pregnant have the option to take what’s commonly called an abortion pill, instead of having a surgical abortion.
An abortion by medication is actually a two-step process involving two medications. The first is mifepristone, given in the PPMM office. Mifepristone stops the pregnancy from growing.
The second medication, misoprostol, is taken at home within the next 48 hours. This medication causes cramping and bleeding that empties the uterus. It usually takes several hours to expel the pregnancy, with possible cramps for one to two more days. Sometimes patients return a week later for another ultrasound; others may be directed to take a pregnancy test at home about a week later to confirm whether the abortion was completed.
Abortion medications are effective, but not 100 percent. For those up to eight weeks pregnant, the medications work 94-98 times out of 100, according to the Planned Parenthood website. With each week, the effectiveness decreases slightly. Sometimes an extra dose of medication is given, boosting the chances of success.
“We talk about the pros and cons of each (surgical and medications) and what fits into their life, and proceed from there,” Dieseldorff says.
Some patients feel taking the medication at home affords them more privacy. For others, the surgical procedure with supportive staff on hand is more desirable and private. It’s usually less time consuming, which is important for anyone with work or family obligations.
CALIFORNIA MAY BE A LEADER IN PROVIDING ABORTION ACCESS, but surprisingly it’s at the bottom when it comes to collecting abortion data. It is one of only three states that do not track abortion statistics. The California Department of Public Health stopped tracking in 1997. There are efforts to change that, especially in the wake of an increased influx of out-of-state patients, but the situation is not likely to improve until next year at the earliest.
The best estimate of the number of abortions in California comes from the Guttmacher Institute, an independent reproductive health research organization. It reports that in 2017 there were 132,680 abortions in California, a 16-percent decline since 2014. The state represented just over 15 percent of the 862,320 abortions in the U.S. The nation saw an 8-percent decline since 2014.
PPMM, with 35 clinics in the central section of California and northern Nevada, performed 23,656 abortion procedures in fiscal year 2021-22, according to its annual impact report. Of those, 76 percent were by medication and 24 percent were onsite surgical procedures.
The organization provides an array of health care services, not just abortions. In 2021-22, they saw 161,408 unique patients, Zamora-Marroquin says, for reproductive health needs and other types of medical care combined.
For PPMM, the increase in out-of-state patients began last year when the Texas legislature passed the Texas Heartbeat Act, Senate Bill 8, banning all abortions past six weeks and allowing private individuals to sue anyone who performs or facilitates an illegal abortion. (To call it the Heartbeat Act is misleading. At six weeks what can be heard is a “flutter” of electrical impulses from an area of the embryo that will become the heart. An ultrasound will detect a heartbeat somewhere between 17-20 weeks, when the heart has developed all four chambers.)
After SB 8 was enacted, PPMM saw the steepest increase in out-of-state patients from Texas residents. About one-third of all out-of-state patients were from Texas, Zamora-Marroquin reports. Between July 1, 2021 to April 15, 2022, PPMM provided abortion care to 80 patients who traveled from out-of-state, double the number from the same time period the year before. Of those, 29 patients came from Texas after SB 8 took effect.
Other states where patients travel from include Arizona and Missouri. Most of those patients are using PPMM clinics near travel hubs, like San Jose, Oakland and Sacramento.
“Planned Parenthood Mar Monte has been preparing for the overturn of Roe v. Wade and as a result, we’ve been able to continue to provide abortion services for Californians, but also people from out of state who seek those services,” Zamora-Marroquin says.
PPMM officials prepared by increasing laboratory capacity and adding health centers, as well as increasing the size of existing centers.
“Most importantly we have been training additional providers to meet the growing need,” Zamora-Marroquin says. For the last three years, PPMM has contracted with additional abortion providers and trained more clinicians. They also strengthened training partnerships with medical schools, residencies and fellowships “as an investment” in increasing the number of providers, she says.
The goal is to make sure that Californians still have as much access as before while serving those in need from other states. “We are deeply committed to continuing the expansion and access to abortion care because abortion services are an integral part of health care and accessing that care should not be dependent on your zip code,” Zamora-Marroquin says.
In Monterey County, many residents – in South County and elsewhere – must drive an hour or more to reach a clinic, Dieseldorff points out. “I think it’s important to know that patients inside California face travel for abortions,” she says. “It’s important for us to keep building the infrastructure within Planned Parenthood Mar Monte to treat patients in their own areas.”
WITH DEMAND FOR ABORTIONS IN CALIFORNIA INCREASING, it seems serendipitous that a new law passed three years ago that will increase access is going into effect on Jan. 1, 2023. That law, Senate Bill 24, requires all public university health centers, including CSU Monterey Bay’s center, to offer abortion medications starting on that date.
At CSUMB, where the university contracts with Doctors on Duty to provide services – it’s one of only two smaller campuses that contract out the services, along with CSU Channel Islands – preparations have been underway and the health center will be ready by Jan. 1, according to a CSUMB spokesperson. (CSUMB officials declined to be interviewed for this story, deferring to CSU officials.)
The CSU system has been preparing since SB 24 passed in 2019. That included providing each campus with a readiness checklist that included information on what needed to be done: training medical staff, identifying licensed providers who are able to prescribe the medications, among a list of other protocols and office procedures.
“We want to help them as much as we can to fly with that law in January,” says Carolyn O’Keefe, CSU director of student wellness and basic needs.
(The CSU did not take an official position on SB 24. “We’re focused on providing health care to our students in an equitable way so that they can be successful,” O’Keefe says. Providing abortion medications is “another service we provide to offer that equitable care to our students,” not unlike other health services provided.)
The costs involved in preparations were covered by $200,000 grants distributed to each campus by the California Commission on the Status of Women and Girls that raised the $10.3 million from private sources to cover all CSUs and UCs. In addition, the commission funded the reproductive health nonprofit Essential Access Health to provide staff training to accommodate the changes, O’Keefe says.
There will be no costs to students for the actual services provided – those are covered by the fees students pay each semester – but they will have to pay for the medication themselves, approximately $50. Currently there is no process available to students who may not have the money, but some campuses are looking into ways to provide funding. O’Keefe says the CSU system has gone back to the commission to ask about providing more funding to help pay for the medications.
How many students will take advantage of the new service is yet to be seen. One 2017 study by the San Francisco research program Advancing New Standards in Reproductive Health estimated that between 3,800 and 6,200 CSU and UC students will be served annually.
AS CALIFORNIA’S PRO-CHOICE ACTIVISTS SAW THE WRITING ON THE WALL with the overturning of Roe, Newsom convened a 46-member steering committee representing reproductive health organizations called the California Future of Abortion Council. In December 2021, the council released a report that outlined numerous policy recommendations and solutions for a post Roe-landscape. Out of that report came a legislative package of which 12 bills successfully passed by the end of the 2022 legislative session and were signed by Newsom, including AB 1666, protecting California abortion providers from being sued by people out of state.
The bills included removing cost-barriers to abortions, training of new providers and clinicians, and a variety of other protections, education and information access (for more information, see sidebar, left).
“As more states enact total or extreme bans on abortion care – leaving millions of people without the ability to access legal abortion care in their home state – California continues to provide a blueprint for what is possible when policy centers people, equity, science and medicine; and trust each person to make the best decisions for themselves and their family about their health care options,” the council said in a joint statement on Aug. 31 as the bills were headed to Newsom’s desk.
Among the 12 bills was Senate Constitutional Amendment No. 10, which went on to become Proposition 1, entitled the Constitutional Right to Reproductive Freedom, and now a part of the California Constitution.
Prop. 1 states: “The state shall not deny or interfere with an individual’s reproductive freedom in their most intimate decisions, which includes their fundamental right to choose to have an abortion and their fundamental right to choose or refuse contraceptives.”
HOBBS, OF WOMEN’S MARCH MONTEREY BAY, was encouraged by the passage of Prop. 1, after what she says were several months of grieving. She appreciated the fact that “there are leaders in our state who care enough to put it into the Constitution.”
Hobbs grew up in a conservative religious household and experienced how women were not considered equal. Starting in high school, she spoke out on “making sure women’s rights were mentioned or considered.”
While a college student in Utah in the early 1990s, Hobbs had an abortion, but in order to do so, she was forced by law to go through counseling first.
“I felt I had already made my decision and I didn’t need other people to tell me that my decision was right,” Hobbs says. She’s been passionate about a woman’s right to choose ever since.
“When I had my abortion I remember it was, ‘hush hush, don’t tell anyone,’” she says. “But abortion is health care, there’s nothing to be ashamed of.”
Talking about it normalizes the procedure: “That’s something I have learned from a lot of the Gen-Zers,” Hobbs says. “They are matter-of-fact about it.”
Because the memo about the overturning of Roe was leaked about a month before the Supreme Court’s decision was announced, the Women’s March had time to prepare for the rally that was held on June 24. It was going to be a chance to grieve together, heal together and galvanize for more fighting.
One of the organizers suggested a ceremony where people could break an object as a way to start the healing process. Hobbs came up with the idea of “smash the plate-riarchy.” People wrote something they were really mad about on plates, then smashed them (safely, in a container). Some plates contained messages, some names of Supreme Court justices or ex-partners. About 50 people smashed plates.
“Until I smashed that plate I didn’t realize how much rage I had,” Hobbs says. “It was pretty powerful to look inside the bottom of the can at the end of the event and see all the different names shattered at the bottom of the garbage can.
“It’s easy to feel overwhelmed and not know what to do with those feelings,” Hobbs says. “The conversation isn’t over, and there’s always space for hope in this situation.”
A look at California’s legislative efforts to codify choice and increase abortion access.
Assembly Bill 657 (Jim Cooper, D-Sacramento): Expedites licensure for abortion providers and clinicians.
AB 1666 (Rebecca Bauer-Kahan, D-Orinda): Protects abortion providers from out-of-state lawsuits, and declares laws elsewhere that authorize such actions “to be contrary to the public policy of this state.”
AB 1918 (Cottie Petrie-Norris, D-Irvine): Creates the California Reproductive Health Service Corps, which will recruit, train and retain a diverse workforce of health care professionals to provide reproductive health services, including abortions.
AB 2134 (Akilah Weber, D-La Mesa): Establishes the California Reproductive Health Equity Program designed to provide grants to providers who provided uncompensated care to patients with low incomes or face other financial barriers to accessing contraception and abortion.
AB 2205 (Wendy Maria Carrillo, D-Los Angeles): Requires health plans under Covered California to report annually the total amounts of funds collected in accounts from which abortions are paid. It’s meant to gain an understanding of how much money is in the accounts and how much is being used each year to pay claims.
AB 2223 (Buffy Wicks, D-Concord): Protects anyone in California from being investigated, prosecuted or incarcerated for ending a pregnancy or experiencing pregnancy loss.
AB 2320 (Cristina Garcia, D-Bell Gardens): Creates and administers a pilot program to direct funds to community health clinics that provide reproductive health care services in five counties to be selected.
AB 2586 (Garcia; Robert Rivas, D-Hollister): Establishes the California Reproductive Justice and Freedom Fund. The fund will support community-based organizations to provide accurate, comprehensive and culturally congruent information about reproductive and sexual health to disproportionately impacted communities.
AB 2626 (Lisa Calderon, D-Los Angeles): Prohibits the removal or suspension of medical licenses for a licensee providing abortion care in California who is complying with California law.
Senate Bill 245 (Lena A. Gonzalez, D-Long Beach): Requires all state-licensed health care service plans to cover abortion services without a co-payment, deductible or any type of cost-sharing.
SB 1142 (Anna Caballero, D-Merced; Nancy Skinner, D-Oakland): Creates an abortion information website managed by the California Department of Public Health to provide information on where to access abortion services, as well as how to obtain coverage or financial support and travel information and resources.
SB 1375 (Toni Atkins, D-San Diego): Allows trained nurse practitioners to provide first-trimester abortions independently.