While Planned Parenthood often reminds the public that abortion only makes up around 3 percent of its services, it is the largest single provider in the country. And thanks to its 100-year history, the non-profit is a household name—and an easy target. We’ve seen that play out over the last few months with the anti-abortion Center for Medical Progress' "sting" video campaign, the hacking of Planned Parenthood's website, and Republican representatives threatening a government shutdown if a measure that would defund Planned Parenthood that they'd tacked onto the country's annual spending bill didn't pass. 

While Planned Parenthood is in many ways the national face of abortion provision, the reality is that its clinics only provide about a third of the nation’s abortion services, according to Nikki Madsen, executive director of the Abortion Care Network (ACN). Independent abortion providers that you'd likely only know about if you lived in their area perform somewhere between 60 and 80 percent of the procedures, says Madsen. These providers vary widely, from a small rural clinic that only does abortions one day a week to a multi state chain. 

Race and Independent Providers

Because they are independent and often for-profit, it's hard to pinpoint the demographics of the women who go to independent abortion providers. So while we know that, according to 2013 data, 14 percent of Planned Parenthood patients are black, 22 percent are Latina and most are on Medicaid, independent providers can choose whether or not to collect race data about their patients. Women of color, particularly blacks and Latinas, have the majority of abortions in this country, and are therefore likely to be using an independent provider.

Unlike the 700 clinics under the Planned Parenthood umbrella, independent abortion providers tend to be for-profit, says Amy Hagstrom Miller* the founder and owner of Whole Woman's Health, a chain of eight clinics in five states. “I [am for-profit] because I see myself as a social entrepreneur trying to solve a social problem through a corporate structure that can move quickly. We rarely make a profit, though.”

Hagstrom Miller's model has been to buy up clinics, most owned by people trying to retire, and then consolidate administrative support across the entities. She considers herself part of the "next generation" of abortion provision, since so many abortion providers are from the Roe v. Wade generation. 

Whole Woman's Health uses the race makeup of the communities they serve as an indicator of its client base. “Overall, the vast majority of our patients in Texas are Latina, but in Ft. Worth and San Antonio there a lot are African-Americans,” says Hagstrom Miller. Many of the clients that use the Twin Cities branch are Hmong and Somali immigrants. 

But many clinics don't have the administrative strength that Whole Woman's Health does. Erin Grant, the office manager at an abortion provider called the Philadelphia Women’s Center, says that independents can be harder to find than a Planned Parenthood and that this difficulty limits the number of women of color who use their services. Madsen says it isn't proven that trouble finding independent clinics changes based on race, but that technology and infrastructure can be barriers to receiving care.

“The majority of people are accessing information about abortion care through handheld devices," she says. "Independent providers are disadvantaged because they don’t have the resources to have applications developed, to upgrade their websites to be mobile friendly or to buy Google ads—things that might bring more patients.”

Clinic Shutdowns and the Struggle to Educate Clients About Their Rights

While Planned Parenthood faces many of the direct, well publicized attacks by anti-abortion politicians and activists, independent providers have also been facing major threats, but without as much of the press or public support. During the recent Republican congressional attempts to defund Planned Parenthood, ACN attempted to address this issue by starting a hashtag,  #Standwithabortioncareproviders, to use with #StandWithPP. 

The first major threat that independent clinics face alongside Planned Parenthood is legislative. The list of new regulations that state lawmakers have passed over the last few years is incredibly long. These changes include longer waiting periods between preliminary exams and the abortion procedure, mandatory ultrasounds, language doctors and nurses must use with patients and changes in clinic requirements or hospital admitting privileges. The Guttmacher Institute calls these provisions TRAP (Targeted Regulation of Abortion Provider) laws and points out that most abortions in the country are performed outside of a hospital setting. 

Hagstrom Miller and her team at Whole Woman’s Health know this all too well. Its Texas branches have been struggling since their Republican-dominated state government passed HB2, a sweeping law that requires abortion clinics to follow the same building, equipment and staffing rules that hospital-style surgical centers do. “We have opened and closed our clinics a number of times since HB2 passed two years ago,” she says. “Until we got [an] injunction, we had to close because we didn’t have any physicians who could get [hospital] admitting privileges.” 

Whole Woman’s Health is now acting as the lead plaintiff in a case about the impact of HB2 that the Supreme Court may hear next term.  A recent study highlighted how these shifts have vastly increased waiting lists in parts of Texas—even up to 20 days for an appointment. 

Hagstrom Miller says that another impact of HB2 is that her team ends up spending a lot of time spreading the word that abortion is still legal. They even founded a non-profit organization called Shift that focuses on educating people about the changing laws. Shift, which is located in the space that the Austin clinic used before it shut down due to the law, has put up billboards and bus ads and they’ve started a hotline. “We spend a lot of time explaining the forced ultrasound and the waiting period [between the preliminary exam and the abortion.]” she says. “It’s absurd, really, that we end up being the educators and enforcers of laws [we don’t support].”

The Impact of the "Sting" Video Campaign 

This summer an anti-abortion activist group calling itself the Center for Medical Progress released dozens of deceptively edited, secretly recorded videos of its operatives discussing fetal tissue donation for medical research with Planned Parenthood workers and other members of the National Abortion Federation. The group, which set up a fake company called Biomax Procurement Services to infiltrate abortion care conferences and hold businesses lunches with Planned Parenthood executives, has claimed that the widely discredited videos prove that the reproductive health care organization illegally sells tissue from aborted fetuses for profit and has a cavalier attitude about "selling baby parts." Republican presidential candidates such as Rand Paul of Kentucky and Ted Cruz of Texas have used the videos to justify several congressional hearings about the charges. Governors including Texas' Greg Abbott and Louisiana's Bobby Jindal, another presidential candidate, have ordered investigations into Planned Parenthood branches in their states. According to The New York Times, the National Institutes of Health devoted $76 million last year to fetal tissue research. Medical researchers use the tissue to create treatments for a range of diseases including H.I.V., hepatitis, congenital heart defects, retinal degeneration and Parkinson’s. 

Philadelphia Women's Center's Grant, who uses the pronoun "they," says they have seen some significant shifts in the culture of their clinic since the attacks on Planned Parenthood intensified. “The debate outside of our doors has become nastier,” Grant says of the protestors who routinely show up at the clinic. “The language that they use to intimidate and shame people coming for services has changed. I’ve heard protesters say, ‘Make sure that you check that they’re not selling your baby.’”

Grant also notes how the political climate has impacted the patient/provider relationship. “Patients are on edge so it turns into a suspect interaction making it feel like everyone is here doing illegal things. We’re all working overtime to make ourselves seem more and more transparent, which makes us feel more suspicious. Then you go the route of overeducating people.”

Madsen says independent providers are facing more harassment and intimidation by what she calls “local anti-abortion zealots.” “All of [our members] got mailed handcuffs last year," she says. "I just talked to one provider who has a protestor [standing] on the street outside of his [home] each month.”

The Cost Challenge

At a time of legislative and cultural challenges, independent clinics dedicated exclusively to abortion care are also facing a business challenge—relatively low fees. “Abortion is fascinating when you look at it the context of health care because our fees are the same as they were 20 or 30 years ago,” says Hagstrom Miller. “We don’t come with a business mind, we come with a human rights and social justice framework. Inflation [of abortion costs] has [only] gone up 11 percent since Roe, when in other health care fields it’s been exponential.” Adds Madsen: “Prices are kept low so that people can pay cash out of pocket.”

But the fees have been challenging for providers, particularly in states that cover the cost of abortions they deem medically necessary, because the reimbursement rate is low. For example, Madsen shared she knows of a clinic in Minnesota where “a second trimester abortion that would cost $2,000 would be reimbursed at [only] $420.” 

Madsen, who notes that the U.S. has lost 153 independent providers since 2011, says the situation is challenging for everyone, whether their state laws are hostile to abortion provision or not. “If you’re in a red state, you’re probably financially doing fine, but the laws are closing you down,” she says. “If you are in a blue state you’re probably not financially doing well, but the laws are fine. Everyone is concerned about how much farther this hostile climate will go, and how much more difficult it will become to find an abortion in this country." 

There is fear that as more clinics close, and the options narrow, the “healthy ecosystem of abortion care,” in Madsen’s words, will be jeopardized. “Abortion care cannot become a monopoly" of clinics that survive, she says. 

Dawn Laguens, executive vice president of the political arm of Planned Parenthood, the Action Fund, agrees. “We fight, often in partnership with groups that represent independent abortion providers, against any legislation that attempts to block women from accessing essential reproductive health care, including abortion. This fight is not just about Planned Parenthood, it’s about ensuring that abortion remains a legal and fundamental right in this country.”

Grant says they're willing to fight for abortion access in part because people who are struggling to make ends meet must have control over their reproductive choices. “People really don’t understand what it’s like right now for people who are thinking of making families. I live in a place where we have a 14-year wait for public housing," they explain. "I work in an abortion clinic because, by being here, I bring dignity. It’s upsetting to me that we are feeling like we can only wring our hands. Abortion is a passion of mine and I’m very proud of where I work. I don’t believe that we have to be in this situation.”

*Article was updated to correct the spelling of Amy Hagstrom Miller