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Health Imperatives

    HEALTH CARE

    DPH Launches Campaign on Risks at ‘Crisis Pregnancy Centers’

    But the state has little power to deny licenses to centers that mislead women

    By

    HYANNIS — In the year since medication abortion became available on Cape Cod for the first time since 2008, the landscape of access has continued to shift.

    The Your Options Medical mobile van, which relocated to Cape Cod from Southbridge last summer, is now licensed as a medical clinic by the Dept. of Public Health. Its host site is St. Francis Xavier Parish in Hyannis. (Photo by Sophie Mann-Shafir)

    Access to prescriptions for those needing abortions has not expanded, though CVS pharmacies have been filling such prescriptions since March. Meanwhile, an anti-abortion van belonging to a so-called crisis pregnancy center based in Revere has gained purchase as a state-licensed medical facility in Hyannis.

    Last month, Massachusetts launched a public education campaign sounding an alarm about the dangers of crisis pregnancy centers (also called CPCs).

    The centers “often mislead people about their options if they are pregnant and dissuade them from accessing abortions,” according to a press release posted by the state. The Healey-Driscoll administration’s initiative has allocated $1 million to expose the misleading advertising and limited services of CPCs.

    Designed by the state Dept. of Public Health (DPH) and the nonprofit Reproductive Equity Now Foundation, the campaign has put out radio and television ads and billboards in English and Spanish warning of the dangers of the centers. A 30-second video published as part of the campaign advises: “Whether you need pregnancy care or abortion care, avoid anti-abortion centers. They may look like medical clinics but can put your health at risk.”

    What’s in a Clinic?

    That the state would license clinics as legitimate medical facilities while simultaneously creating a first-in-the-nation campaign to educate people about their dangers reflects the fact that, according to a DPH spokesperson, there is no distinct licensure designation for crisis pregnancy centers or anti-abortion centers in Massachusetts. The department also confirmed that such places may be licensed as clinics if they offer medical services such as ultrasounds.

    “These crisis pregnancy centers have demonstrated they are not trusted medical providers, and I hope the state will take further action to rein in any deceptive activities that these facilities may be engaged in,” state Sen. Julian Cyr told the Independent on Tuesday.

    The DPH earlier put out information about the dangers and compliance requirements of anti-abortion centers in January, following what the DPH spokesperson wrote were “several complaints against anti-abortion centers.”

    The state’s January statement cautioned that most CPCs are not licensed and are instead funded and controlled by religious and/or advocacy organizations seeking “to advance an anti-abortion agenda.”

    At the end of May, the Independent received documents from the DPH showing that as of Feb. 19 of this year the Your Options Medical mobile van, which had been under DPH investigation since the fall, had its medical license officially re-approved, with St. Francis Xavier Church in Hyannis as its host location.

    Documents released this spring show that the van’s compliance issues were essentially bureaucratic: the clinic was cited by DPH for problems like parking in lots without formal approval from property owners and for advertising ultrasound and pregnancy testing services even when its operations were temporarily on pause.

    More CPCs Than Providers

    According to Reproductive Equity Now, there are currently 34 CPCs in Massachusetts — more than twice the number of clinics offering reproductive care. Nationwide, CPCs outnumber clinics that offer abortion as an option three to one, according to Planned Parenthood.

    There are currently four anti-abortion clinics that are also licensed as medical clinics by DPH: ClearWay Clinic’s branches in Worcester and Springfield, Care Net Pregnancy Resource Center in Fitchburg, and the Your Options Medical mobile van in Hyannis with its parent location in Revere.

    A frequent criticism of CPCs is that they strategically open near women’s health clinics in order to confuse patients seeking comprehensive care. Caroline Kimball-Katz, director of communications and marketing at the Planned Parenthood Advocacy Fund of Massachusetts, told the Independent that CPCs have set up shop very near two Mass. Planned Parenthood clinics, one in Worcester and one in Marlborough.

    “Patients sometimes are in the crisis pregnancy center for over an hour, sometimes multiple hours, before they realize they’re in the wrong place,” said Kimball-Katz. The experience “rattles a lot of patients and frankly can really break trust in the health-care system.”

    Julia Kehoe, CEO of the only clinic offering abortion prescriptions on Cape Cod, said she had not seen the Your Options Medical van parked near Health Imperatives and that it did not appear to be affecting her clinic.

    While reproductive health clinics are generally most concerned about stationary CPCs opening their doors nearby, one concern women’s health advocates have about the mobile CPCs is that they’re difficult to track, researcher Carly Thomsen told the Independent last fall. They don’t have to report their schedules or whereabouts and thus have an easy time dodging official scrutiny.

    On a June Friday in the late morning, the van was not parked at St. Francis Xavier. A secretary in the parish office who declined to give her name said the van is usually stationed there.

    “They’re under our auspices, but they don’t tell us when it’s being staffed,” the secretary said. She said information about the van spreads mostly by “word of mouth.”

    A schedule from last fall that Nancy Jamgochian, a licensed nurse affiliated with Your Options, sent to DPH lists four locations where the van planned to park during October and November. All were in Hyannis, including the Hyannis Transportation Center and Alberto’s Ristorante.

    Medication abortions on Cape Cod are available only at Health Imperatives, the seven-clinic organization with a branch in Hyannis. (Pregnancies past the 10-week gestational window require procedural abortions, and patients must leave the Cape for those.)

    Outer Cape Health Services still does not provide abortions, according to a person answering the telephone at its Provincetown clinic on July 19. Cape Cod Healthcare, which owns the Cape’s two hospitals and several other medical facilities, still provides abortions only in cases “when a woman’s life is in jeopardy,” according to a statement issued Sept. 30, 2022 that marketing and communications director Julie Badot sent again to the Independent this week. She confirmed that nothing had changed since then.

    Before Health Imperatives began providing abortions last summer, people in Provincetown seeking those services had to drive more than 100 miles to clinics in Boston or Attleboro. Trips to either place can take more than two hours.

    Health Imperatives began offering medication abortions in July 2023 and as of June 21 had provided 105, according to Kehoe.

    “That shows that there is the demand that we knew there to be,” she said.

    With the wealth gap growing, Kehoe said, she worries that it is getting harder for all people to access the high-quality care they deserve. Health Imperatives will provide services regardless of a patient’s immigration status or ability to pay. (Without insurance, the cost of a medication abortion is $400, Kehoe said.)

    With abortion access under threat nationally, Kehoe said “it is a very challenging time” for reproductive health. But she was grateful for the state’s campaign and the commitment to access among others here.

    “I can’t imagine a better place, with the public officials that we have here, and the advocates, and the health-care providers,” she said.

    HEALTH CARE

    Cape’s Only Abortion Care Clinic Prepares to Manage With One Medication

    Providers get ready to adjust, should Supreme Court restrict mifepristone

    By

    HYANNIS — Six months ago, Health Imperatives became the only clinic on Cape Cod to offer medication abortion, ending the Cape’s 15-year period as an abortion care desert. Now the organization, like others around the country, is facing a threat that could hinder its current approach to care.

    The U.S. Supreme Court in December agreed to hear a case brought by an anti-abortion coalition, the Alliance for Hippocratic Medicine (AHM), that seeks to restrict abortion by challenging the FDA’s approval of mifepristone, one of two pills used in most medication abortions. The court is expected to begin hearing oral arguments on March 26.

    Health Imperatives prescribes mifepristone along with misoprostol — to be taken 24 to 48 hours apart between 6 and 10 weeks of gestation. This regimen now accounts for more than half of abortions nationwide, according to the Guttmacher Institute.

    Mifepristone, which blocks progesterone, was initially approved as safe and effective for terminating pregnancy by the FDA in 2000 and has been endorsed by the World Health Organization, the American College of Obstetricians and Gynecologists, and the American Medical Association. Current data at the Guttmacher Institute show that mifepristone is now approved for this use in 96 countries around the world.

    Health Imperatives Director Julia Kehoe told the Independent that, if necessary, the organization’s clinics would continue offering medication abortions in the form of misoprostol alone.

    According to 2020 research published in the National Library of Medicine, misoprostol-only abortions are safe during the first trimester of pregnancy, with an efficacy rate between 85 and 95 percent.

    According to Kehoe, the Health Imperatives Hyannis clinic has prescribed medications for 45 abortions since July and for 175 across its seven locations in southeastern Massachusetts.

    Kehoe told the Independent last summer that the organization received 500 doses of mifepristone after Mass. Gov. Maura Healey issued an executive order to stockpile the medication across the state. Healey’s order followed a ruling in Amarillo, Texas, where U.S. District Judge Matthew J. Kacsmaryk — a Trump nominee with anti-abortion views — is the sole sitting judge, according to the Texas Tribune. That move initiated the fight over the drug that has reached the Supreme Court.

    If AHM’s lawsuit succeeds, the Court’s decision could limit access to the medication even in states like Massachusetts, where recent legislation aims to safeguard providers from national attacks on reproductive care. The ruling could prohibit mifepristone from being prescribed through telehealth and mandate that only physicians may write prescriptions for the drug, even in a state where physician assistants, nurse practitioners, and nurse-midwives can all provide abortion care.

    According to Kehoe, all 45 medication abortions prescribed at the Health Imperatives center in Hyannis included visits to the office, though some patients opted to take the pills at home.

    When patients come in with a pregnancy with a gestational age beyond the 10-week window, the clinic works with them, Kehoe said, referring patients elsewhere for procedural abortions. Procedural abortions are legal in Massachusetts up to 20 weeks and six days of a pregnancy.

    The closest provider offering procedural abortions is Four Women Health Services in Attleboro, 111 miles from Provincetown.

    To help abortion-seekers from the Outer Cape with logistical challenges, Health Imperatives used a grant from the state Dept. of Public Health last summer to hire “navigators,” Kehoe said. They work to reduce stress by helping arrange for transportation and hotel stays if needed, she said.

    Kehoe said that telehealth is also available for those who can’t make the trip. But strict eligibility requirements already exist for telehealth services, according to Dr. Danielle Roncari, vice president of medical services for the Planned Parenthood League of Massachusetts.

    To qualify for a prescription by telehealth, a patient’s last menstrual period must have occurred within 11 weeks and the patient can’t be in any pain, because that might indicate a potential ectopic pregnancy or another complication that could require direct medical intervention.

    Still Just One Clinic

    The question remains as to why Health Imperatives is still the only health center on Cape Cod to offer abortion services. Some other providers cite the Hyde Amendment, which prohibits the use of federal funds for abortion care.

    “We are just following the federal guidelines,” said Dr. Arshiya Seth, chief medical officer of the Community Health Center of Cape Cod, which runs five clinics on the Upper and mid-Cape.

    But federal guidelines don’t prohibit abortions outright, according to guidance by the Reproductive Health Access Project, a national network of primary care providers working to expand abortion, contraception, and miscarriage care.

    As a federally qualified health center, the Community Health Center of Cape Cod qualifies for specific reimbursement under Medicare and Medicaid. While the Hyde Amendment restricts these types of centers from using federal funding for abortion care, other funds can support this care, according to the Reproductive Health Access Project.

    Outer Cape Health Services, also a federally qualified health center, first cited the Hyde Amendment last year in explaining why it does not offer prescriptions for abortion medications. It changed its answer to say the reason is that its clinics are focused on primary care. OCHS Communications Director Gerry Desautels told the Independent on Jan. 18 that there has been no change since.

    Cape Cod Healthcare, the parent organization that operates both Cape Cod Hospital and Falmouth Hospital, also restricts abortion care.

    In a statement provided to the Independent by Communications Manager Lisa Connors on Jan. 8, Cape Cod Healthcare confirmed that it provides abortions only “when a woman’s life is in jeopardy” and “to preserve the health of the mother.” An ethics committee is not involved, the statement said. The decision is reached privately between patient and provider.

    If an abortion is not “urgent,” the statement continued, the pregnant patient is referred to “providers with a greater degree of expertise.”

    HEALTH CARE

    40 Days of Anti-Abortion Protests Planned at Health Clinic

    Cape chapter of a Texas group says it will hold prayer vigils

    By

    HYANNIS — For 15 years, people seeking abortions had to leave Cape Cod for care; the nearest clinic was over 100 miles away. But in July, Health Imperatives opened in Hyannis. It is the only clinic where women can get prescriptions for abortion pills on the Cape. A group fighting abortion rights is planning protests at that clinic beginning next week and continuing into November.

    That group is a local chapter of the Texas-based “40 Days for Life” campaign, whose slogan is “The beginning of the end of abortion.” They are planning what they’re calling daily “vigils,” from Sept. 27 to Nov. 5, gathering outside Health Imperatives bearing signs and reciting prayers.

    Julia Kehoe, executive director of Health Imperatives, said the clinic is aware of the protesters’ plans.

    “Our primary concern is the health and safety of our patients, so we are planning on having a police detail onsite,” said Kehoe. Police will be present at the beginning of the campaign, she said, and plans will evolve from there.

    “The police are also planning on driving by several times a day just to make sure that things are peaceful, which we’ve been assured they will be,” Kehoe said. She added that protesters will not be able to park in the Health Imperatives parking lot or draw closer to the building than the sidewalk in observance of the clinic’s buffer zone.

    That buffer zone has not been a sure thing since the Supreme Court struck down a rule establishing 35-foot protective areas around women’s health clinics. But under Massachusetts law, the police can enforce a 25-foot buffer if they see that patients’ access is impeded.

    The 40 Days for Life campaign is aware of the buffer zone rule. Its vigil “dos and don’ts” handout directs participants not to park in the Health Imperatives lot and not to “go on the grass or block the driveway of Health Imperatives parking lot.”

    That leaflet was distributed at an organizing meeting at Corpus Christi Parish, a Catholic church in East Sandwich, on Sept. 8. There, organizers “cast the vision” for the protesters, modeling the protest after others organized by the 40 Days group, which is headquartered in Bryan, Texas. It claims to have shut down 145 abortion clinics since it formed in 2007.

    A variety of printed materials were on offer at the meeting in East Sandwich, including two booklets of “prayers to end abortion,” a 40 Days-branded devotional guide, and a 40 Days-sponsored pamphlet about medication abortion.

    Medication abortions, which have been FDA-approved since 2000, consist of two pills: mifepristone, which blocks the hormone progesterone and keeps the fetus from growing, and misoprostol, which expels the fetus. The pills are taken 24 to 48 hours apart.

    The 40 Days brochure about medication abortion contains several statements not supported by science.

    “Abortion pills break a woman’s healthy reproductive system,” the brochure claims.

    The word “break,” said Dr. Nicola Moore, an abortion provider who lives in Truro, “suggests that something about the woman changes. Nothing about the woman changes in any permanent way.” In terms of harm to the woman, said Moore, there is none: “She has come to you asking for help with a pregnancy she doesn’t want, and you’re helping her.”

    The brochure also says that medication abortions are not safe, quoting testimony from people who describe intense and painful side effects.

    Moore drew a distinction between pain and danger. “The pill can be very unpleasant,” she acknowledged. “Labor can also be very unpleasant, and many more people get sick having a baby than using the abortion pill.”

    A 2012 study comparing the safety of abortion and childbirth in the U.S. found that childbirth was 14 times more likely to result in death than abortion. Citing that research, “The controversy surrounding pregnancy termination is exceptional in its treatment of abortion as anything but a medical procedure,” wrote Adebayo Adesomo in Scientific American last year.

    Anti-abortion centers, which have been called crisis pregnancy centers or CPCs, number more than 30 in Massachusetts. They advertise themselves as resources for pregnant women considering their options but do not offer abortion as an option. And although they refer to themselves as clinics, they are usually staffed by nonmedical personnel.

    The Mass. attorney general has issued warnings about CPCs’ limited service options, which are often unknown to their clients because of deceptive advertising.

    At the 40 Days vision meeting, Mass. Citizens for Life President Myrna Maloney Flynn of Northampton warned Sandwich parishioners about a state bill that she said would “censor” crisis pregnancy centers. She told the group that the legislation would require centers “to be very careful in terms of what words they used on their websites and in any kind of print promotion.”

    Flynn told the group she was referring to H.377, “An Act to Protect Patient Privacy and Prevent Unfair and Deceptive Advertising of Pregnancy-Related Services.” Submitted by Rep. Tram Nguyen of Andover, the bill would preclude limited-service pregnancy centers from making any claim to the media and on their own websites and materials that “is deceptive, whether by statement or omission.”

    A mobile van from the crisis pregnancy conglomerate Your Options Medical has been roaming Cape Cod since shortly after Health Imperatives began offering abortion services. The van’s exterior claims to offer immediate ultrasound results, which Your Options Medical’s Director Teresa Larkin told the Independent are “preliminary findings,” not actually coming from a registered physician.

    At the protestors’ vision meeting on Sept. 8, Larkin said that the mobile medical van recently had “an issue” with the Dept. of Public Health, which she said was “the tip of the hand of somebody wanting to shut us down. We believe it’s been resolved,” she said.

    According to DPH, a clinic renewal license for the mobile unit and its brick-and-mortar parent site in Revere was issued on July 12. Then, on Aug. 30, DPH conducted a clinic licensure renewal survey at the mobile unit. “Onsite inspections are unannounced without prior notice in order to determine compliance with regulations,” according to DPH. The Independent is awaiting results of the inspection from a public records request.

    “I would not be surprised that the Dept. of Public Health is bringing some scrutiny to crisis pregnancy centers, given that they’re masquerading with what services they’re providing,” said state Sen. Julian Cyr.

    While Health Imperatives director Kehoe said it is possible for patients to get abortion care in telehealth appointments, most prefer to come in person. From a medical perspective, she said, that’s also ideal: “It is preferable for people to come in for the first dose and speak with a provider,” said Kehoe.

    There are multiple organizations operating where the Hyannis branch of Health Imperatives is located. Kehoe said that gives patients a sense of security.

    “People will not know who is coming in for what service,” she said, “and people should not be nervous or let these protesters get in the way of their accessing whatever service it is that they need.”

    REPRODUCTIVE HEALTH

    Hospital Expansion Could Trigger Abortion Access Review

    The Dept. of Public Health could put pressure on Cape Cod Healthcare

    By

    HYANNIS — A proposed $137-million expansion of Cape Cod Hospital could potentially be held up or denied by the Mass. Dept. of Public Health (DPH) because the hospital’s parent organization, Cape Cod Healthcare, restricts access to abortion. The plan was posted on a state website earlier this month and reported by the Boston Business Journal.

    The DPH is required to review all such plans and make a “determination of need.” The law under which DPH approves or denies expansion plans explicitly cites access and quality of care, and it invites community comment. It’s not clear, however, whether the DPH could literally condition approval of the hospital expansion on the provision of abortion services. DPH’s style seems to be to cajole rather than to issue orders.

    As the Independent reported last week, the two major providers of medical care on the Lower and Outer Cape — Cape Cod Healthcare (CCHC) and Outer Cape Health Services (OCHS) — both refuse to offer most abortion services. CCHC, which runs both Cape Cod Hospital and Falmouth Hospital, provides abortions only in urgent situations. OCHS says that it cannot provide abortions because it is a federally qualified health center restricted by the Hyde Amendment.

    (In a letter to the editor in this issue of the Independent, Dr. Ronald Gabel of Yarmouth Port, the former medical director of a surgery center that provided abortion services, argues that OCHS is not in fact prevented from providing abortion care by the Hyde Amendment, provided that federal funds are not used to pay for it.)

    A third nonprofit medical group, Health Imperatives, which operates seven clinics in Southeastern Massachusetts including one in Hyannis, has so far resisted requests to add abortion services.

    Women in Massachusetts have an unrestricted legal right to abortions up to 24 gestational weeks of pregnancy — assuming that they can find a provider.

    “Southeastern Massachusetts is an abortion access desert,” Dr. Jennifer Childs-Roshak told the Independent this week. She is the president and CEO of the Planned Parenthood League of Massachusetts.

    “Abortion is health care,” said Childs-Roshak, “and access should not be based on one’s zip code, identity, or income level. We are committed to working with existing reproductive health-care providers on the Cape and across Southeastern Mass. to establish and expand abortion services, because everyone deserves access to care close to home.”

    Planned Parenthood operates four clinics in Massachusetts, but none on the Cape.

    The state has some leverage to improve access to abortion, but it’s not clear how hard the DPH is pushing, despite Gov. Charlie Baker’s stated commitment to defend and expand reproductive rights.

    Last year, DPH blocked a proposed $2.25-billion expansion by Mass General Brigham to build outpatient care centers in Woburn and Westborough on the grounds that it would raise costs by substituting a teaching hospital that bills at high rates for community hospitals and clinics that bill at lower rates.

    Health Imperatives, which is funded by DPH, has clinics in Hyannis, Wareham, Plymouth, Nantucket, Martha’s Vineyard, New Bedford, and Brockton. The Independent has learned that the DPH has been urging Health Imperatives to provide medication abortions. Health Imperatives’ website displays a wide range of reproductive and health services, including testing and treatment of sexually transmitted infections, birth control, pregnancy testing, cancer screening, and “gender affirming hormone therapy for all genders” — in short, everything except abortion.

    In spite of the discussions with DPH, Health Imperatives CEO Julia Kehoe says that will not change.

    “Currently, Health Imperatives has no plans to provide abortion-related services to our clients,” Kehoe wrote in an email to the Independent. “Since the overturning of Roe v. Wade, we have had several discussions in our community and with advocacy groups about the lack of direct abortion-related services in the area and while it is concerning, we must allocate our limited resources where they are needed most.”

    A DPH spokesperson was unwilling to say that the department would insist on abortion services. “All DPH-funded sexual and reproductive health programs are encouraged, but not required, to provide abortion services as a part of full spectrum of reproductive health care,” the spokesperson said by email. But there is high interest on Beacon Hill in protecting and expanding abortion rights, and pressures on both community facilities and state agencies like DPH are likely to intensify.

    Massachusetts is one of 16 states whose Medicaid program (MassHealth) fully covers abortion services. This is permitted, even though Medicaid is a state-federal program, as long as the abortion services are paid with state funds. Advocates want the Biden administration to change the rules so that federally qualified health centers like OCHS can provide abortions services.

    President Biden issued a general executive order on July 7 to defend abortion rights. He gave the Dept. of Health and Human Services 30 days to write specific rules.

    Editor’s note: An earlier version of this article, published in print on July 21, incorrectly stated that Dr. Gabel was the director of a women’s health clinic. He was the medical director of an ambulatory surgery center that provided abortion services.

     

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