“Reproductive health is not a priority here,” Mayra I Díaz Torres, the program director of Clínica IELLA, tells Remezcla. “That’s before María. Now, it’s even worse.”
Nearly two years after Hurricane María ravaged Puerto Rico, killing thousands, wrecking the power grid, and deepening an already-devastating economic crisis, clinics on the island have seen a decline in abortions. Providers fear it might be because women were forced to carry unwanted pregnancies to term due to the absence of family planning care after the storm.
“We don’t know if there are less women who need abortions, if they left the island, or if they had those children, and if they did, if they carried out unwanted pregnancies, but it was a lot less than the year before María,” says Díaz Torres, whose San Juan-based nonprofit abortion clinic was closed for nearly four months following the hurricane.
According to the Journal of Population Economics’ 2008 study, the aftermath of a natural disaster is associated with increased birth rates. In Puerto Rico, where there was no power or communication and limited access to passable roadways or running vehicles, there weren’t many options on how to pass the time, widening the opportunity for sexual activity. Even more, with pharmacies and hospitals closed down across the island, many were unable to refill their birth control prescriptions or purchase condoms which increases the likelihood of pregnancy.
“People try to maintain a little bit of normalcy through togetherness, so you’re going to have sex. While this could be important for your relationship with your partner, it also makes you vulnerable,” says Dr. Yari Vale Moreno, a clinic administrator and obstetrician in San Juan. “The fact that you don’t have birth control, your condom was overheated and broke, or you cannot get a Plan B brings more turmoil to an already bad situation.”
Vale Moreno, who teaches family planning to students at the University of Puerto Rico School of Medicine, also tells me that the rise in pregnancies following calamities brings a greater need for abortion care. Such care is especially needed for those who already have other children as well as for survivors of intimate partner violence and sexual violence, which surges after catastrophes.
“The worst thing that can happen to you during uncertainty is getting pregnant,” she says.
But in post-María Puerto Rico, the procedure, which physicians and activists agree is typically inaccessible to those who need it on the archipelago, became even more difficult to obtain.
Of six abortion clinics on the main island, only Moreno’s was operating in the storm’s immediate aftermath. The center, located in the metropolitan area, opened nine days after María hit. The facility, which lost its cistern in the hurricane’s 155-mph winds and didn’t have two air conditioning units or its heating system, ran on a generator for three months. With diesel costing double what Moreno paid in electricity before September 20, 2017, she had to cut the clinic’s hours of operation, though she remained open every day of the week. “I think more for mental sanity than anything else,” she says.
“The reality was that there were a lot of women who couldn’t access care because of the limitations of transportation.”
Understaffed, Moreno, who had two nurses leave just before the storm, had only one available on her team at the time. Yet, as the only operating clinic, abortion providers were referring patients to her facility. In the three months that followed the storm, she saw one to six new patients daily, many of them seeking terminations. About 50% of them came from outside of the San Juan area, a usually difficult trek made more strenuous with debris-ridden roads, damaged cars, and scant gasoline.
“The reality was that there were a lot of women who couldn’t access care because of the limitations of transportation,” Moreno says.
Cost was another problem. According to the Center for Economic and Policy Research, nearly 40,000 of Puerto Rico’s 3.3. million residents lost their jobs in the first month after the storm. Additionally, because the Hyde amendment bars the use of federal funds to pay for abortions, people who were out of work could not use public insurance like Medicaid for the procedure.
By the time some of these women saved or borrowed enough money, secured travel to Moreno’s clinic, or were able to find childcare for their other children, they were further along in their pregnancies, resulting in a hiked price for the procedure.
In Puerto Rico, the cost of a first-trimester abortion is about $275. To terminate a pregnancy after 24 weeks could cost as much as $2,400. On the island, Moreno’s clinic is the only one that administers late-term abortions.
“Sometimes I saw women who had irregular periods and didn’t know they were pregnant, so they were more advanced when they saw me,” she says.
With pharmacies closed, especially in the countryside, people lost access not just to contraception but also to pregnancy tests that could alert them of their gestation before they reached their second trimester.
In Loíza, an impoverished municipality east of San Juan, Taller Salud was among the few organizations including pregnancy tests in their relief kits for community members.
“In the distribution of basic provisions for people, and specifically for women, no one was thinking about condoms, Plan B, or pregnancy tests – basic necessities you need to make important decisions. They were giving sanitary pads and toilet paper, and thinking, these people will manage,” says Tania Rosario Méndez, the executive director of the feminist organization.
After María, the nonprofit provided licensed psychological services to people’s homes, organized educational talleres, and distributed special women-directed boxes that included items for their sexual and reproductive health.
“The health of a nation begins with the health of its women: physically, emotionally, and spiritually,” Rosario Méndez says. “While this has always been true, it’s even more true now.”
And in Puerto Rico, women’s health care has long been shoddy – about 65% of pregnancies are unintended, compared to 45% on the mainland. Additionally, while an estimated 138,000 women of reproductive age do not seek pregnancies, the Centers for Disease Control and Prevention reports they are not using effective contraceptive methods due to its limited availability, especially of long-acting reversible contraceptives, high cost, and lack or incomplete insurance coverage. Additionally, the population has higher rates of infant mortality and low-birthweight infants than anywhere else in the U.S., which experts attribute to elevated levels of stress.
Contributing to the island’s heightened anxiety was its Zika epidemic, which impacted at least 1 in 7 newborns between 2016 and 2018. The epidemic was then followed by the catastrophic hurricanes, which shut down 66 of Puerto Rico’s 69 major hospitals, all while the fiscal control board makes major health care cuts. The territory has a higher poverty rate than any U.S. state, with 50% of its residents qualifying for public health insurance, yet it gets less money and resources from the federal government to fund these programs. While Washington pays upwards of 70% of Medicaid expenses in several states – because of a 1968 law capping the amount of Medicaid money it sends to its territories – the government pays only about 19% of Puerto Rico’s Medicaid costs, and it does so as a fixed annual payment or block grant. Governmental officials have issued warnings that the island would soon run out of additional Medicaid funds provided by the Affordable Care Act, and that 900,000 Puerto Rican residents would consequently lose coverage, yet it has responded with additional slashes to health services, compelling indispensable doctors and health care professionals to flee for work opportunities and inflaming an already-cataclysmic health care crisis.
The health of a nation begins with the health of its women: physically, emotionally and spiritually.”
“We talk a lot about María, which was a natural disaster, but not every disaster in Puerto Rico is natural,” says Michel Collado Toro, Taller Salud’s facilitator of sexual and reproductive education. “The worst disaster is its colonial status, the fiscal control board, [and] the limits this illegal junta has put on funding for medical services and community development.”
A major concern for reproductive rights advocates right now is the diminishing number of abortion providers on the island. Back in the 1990s, Puerto Rico had more than a dozen clinics. There are now only six left – five of them in the metropolitan area – and half are managed by providers who are more than 70 years of age. Because of the number of doctors leaving the island, Moreno is concerned there won’t be physicians to take over the clinics when the current owners retire. Additionally, in the more than 10 years she has been teaching, she laments that she has not been able to sell the idea of including family planning in services, largely due to the shame tied to abortion.
“There’s stigma, even if the doctors believe women should be able to make their own choices,” she says. “Depending on where you come from, that could bring a lot of problems. If you’re in a small town and the community finds out you’re doing terminations, people are not going to go to you, and this will put your business at risk overall.”
That pushback, largely rooted in pervasive religious doctrine, has recently ignited another reproductive health care battle: brazen attacks on abortion rights. As of now, the Puerto Rican government allows abortions at any point of the pregnancy as long as they’re offered by one of the few licensed providers on the island, but this right is increasingly under threat. In March, the Puerto Rico House of Representatives voted to pass Proyecto del Senado 950, a measure that adds multiple nonessential and onerous regulations on clinics and requires pregnant people under the age of 18 to receive consent from their parents or legal guardians before obtaining abortion care. While Gov. Ricardo Rosselló vetoed the bill, the Senate vowed to override his decision. “We intend to go over the veto,” Senate President Thomas Rivera Schatz said. Soon after, Sen. Miguel Romeri asserted he would vote against the senatorial majority’s intention to rescind the governor’s veto, making it unlikely for Rivera Schatz to follow through on his promise.
However, the future of abortion rights on the island remains in peril. PS950, authored by Sen. Nayda Venegas Brown, an evangelical pastor and pro-statehood legislator, was introduced in 2018. Her original bill included a series of restrictions that pro-choice activists call a culmination of all the anti-abortion laws being passed in the States: a 48-hour waiting period, a ban on abortions after 20 weeks of gestation, parental consent for patients under the age of 21, and a sentence of up to 15 years of prison for providers who violated the law, among other constraints. While her amended bill softened restrictions, Brown has not shied away from sharing her intention, saying in March, “I wish this was a bill to ban abortion.” Recognizing that Roe v. Wade, which applies to the island, makes that desire unattainable, she suggested that the measure would just be the first of many more anti-choice bills she plans on proposing.
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“To have an abortion is to have access to health care, and this government doesn’t get that, and they want to restrict and they want to build barriers to access that are not necessary,” says Torres, whose clinic is the only one that provides abortion care for teens without parental consent and would have been directly impacted by the legislation.
Through the campaign Aborto Libre, Seguro y Accesible en Puerto Rico, Torres and other reproductive rights activists, abortion providers, lawyers and educators are fighting back against the political strikes on abortion. Since 2018, the group has resisted PS950 and amendments to the Civil Code through actions, storytelling, education, and community engagement. They maintain abortion is a fundamental human right that must be a safe, accessible and affordable option for those who need them, especially the most vulnerable. For Torres, this particularly means impoverished termination-seeking patients, including those who travel to the island for care from across Latin America, largely the Dominican Republic.
“They say poverty has a woman’s face, and it’s true,” she says. “If you have the money, you will never have to go full term with a pregnancy you don’t want. You are going to find a way. But poor women aren’t as lucky. We carry the burden of bad laws and of this crisis.”
At IELLA, the clinic Torres heads, her team serves mostly low-income, often young, communities. An initiative of Profamilias, a nonprofit organization that has provided reproductive and sexual health care and education in Puerto Rico since 1954, services at the facility are modestly priced and available to people without health insurance. With grants from the National Abortion Federation (NAF) and the International Planned Parenthood Federation (IPPF), 20% of abortions administered at the clinic come at no cost to the patient.
But Torres maintains that the hard work she and her colleagues do every day remains insufficient. In a territory where nearly half the population lives below the poverty line and must travel – via an island-long commute or a burdensome ferry from one of its island-municipalities – to attain the service abortion, regardless of its legality, abortion remains a health care procedure beset with impediments.
“Abortion is legal in Puerto Rico, but it is not accessible,” Torres says. “The current battle is to make it even more inaccessible.”