WASHINGTON, D.C. — Kate Cockrill has asked a lot of women what it was like to have an abortion. Some of the answers she gets are stark.
“One of the interviews I did a couple years ago was with a woman who had an abortion in Arkansas. She said that getting an abortion felt like a drug deal,” Cockrill, who has conducted several studies on abortion and is currently the executive director of Sea Change, a nonprofit dedicated to challenging the stigma around reproductive health experiences, said.
The pervasive stigma associated with ending a pregnancy influences patients’ assumptions about what will happen once they walk through the doors of an abortion clinic. They may imagine that abortion is a frightening or dangerous procedure. They might be intimidated by the tight security measures in place to protect abortion providers against violence and harassment. They could encounter aggressive protesters on the sidewalk. And, thanks to the highly publicized flood of restrictions on abortion over the past several years, they may wonder whether these clinics are even allowed to continue offering the procedure in the first place.
Cockrill understands why the Arkansas woman had that reaction. “She entered a space that had an armed guard outside, people milling around outside, bars on the window. And she had to pay cash,” she recounted. “It was a quality health care provider that was taking precautions because of the environment of stigma around abortion — but from a patient’s perspective, it can actually reinforce this sensibility that they’re doing something illicit and wrong.”
When Cockrill asked that interview subject what she would have preferred for her abortion experience, she said she wished it had been more like a spa.
That interview took place more than five years before Carafem, a health clinic in the D.C. metro area that’s recently made headlines for touting its spa-like atmosphere, first opened to the public. But it was a prescient commentary about what women are looking for in an abortion provider.
Carafem president Christopher Purdy, who has a background in global health, decided to launch the new clinic after observing that the abortion pill is more accessible in many foreign countries than it is in the United States. Purdy and his team were interested in eliminating some of the barriers that make it difficult for U.S. women to obtain an abortion.
CREDIT: Courtesy of Carafem
One of those barriers, they decided, can be the environment that patients first walk into and their subsequent expectations about how they’re going to be treated.
You can’t get a pedicure or a facial at Carafem — but you can sit back on a purple couch and take the abortion pill in an environment that feels much warmer than a traditional doctor’s office. The clinic offers the full range of birth control options as well as medication-induced abortion up to 10 weeks of pregnancy.
“It was important to us to have natural wood finishes, natural light, nicer finishes, spaces that look really clean,” Melissa S. Grant, the vice president of health services for the clinic, explained during a tour of Carafem’s facilities. “We want to challenge the social myth that abortion clinics are scary, that they’re these sad places where no one would ever want to work, that you can walk in and tell immediately it’s an abortion clinic. This health center doesn’t feel that way.”
Carafem, which has been serving patients for about eight months, is tucked away in a large office building in an affluent neighborhood on the outskirts of the nation’s capital. The organization’s name is just a tiny line in the expansive directory in the lobby, which makes riding the elevator up to the health center feel a bit more anonymous than walking into a standalone Planned Parenthood clinic.
One thing that helps Carafem feel indulgent is the high level of convenience and ease it extends to people interested in its services. You can call, text, or chat a staff member at any time to book an appointment, and they can be flexible enough to fit you in the very next day. Appointments typically don’t last longer than an hour.
Once you’re in the door, you’ll encounter a small health center flooded with sunlight and adorned with photographs of diverse women having casual conversations over coffee. Floor-to-ceiling wooden cabinets keep medical equipment tucked out of sight (the goal was to banish anything “that takes your focus away from being able to relax and ask questions,” according to Grant). The bathroom is painted a cheerful shade of bright pink. Tables curve into an oval shape to help foster back-and-forth conversation, rather than making you feel like you’re being lectured.
There’s a lofty goal behind Carafem’s careful attention to these details: “It’s our hope that when a patient enters this facility, she’ll feel at peace and at ease because she doesn’t feel like she’s hiding this secret,” said Carin Postal, the organization’s communications director.
CREDIT: Tara Culp-Ressler
That’s a sharp departure from the way the abortion procedure is typically treated in mainstream U.S. society. As a deeply stigmatized reproductive health experience, abortion is shrouded in secrecy and shame. Many of the people who choose to end a pregnancy receive the implicit message that they’ve done something wrong. Thanks to particularly extreme abortion opponents, they’re even told that they’re murderers.
In the health center’s small waiting area, visitors can peruse handwritten cards with glowing feedback about Carafem that are propped up on each side table. “Above and beyond any medical experience I’ve had as a woman,” one card reads. “I was nervous and unsure about a lot but put at ease immediately,” reads another. A survey conducted among the organization’s clients found that an impressive 100 percent say they would recommend Carafem to a friend who needed reproductive health services.
The appeal is obvious. If you need to get an abortion, why shouldn’t that experience be as comfortable and luxurious as possible? Wouldn’t anyone want that for themselves?
“If I were seeking out abortion care, I would be very drawn to an abortion provider that characterizes its services like a spa,” Cockrill agreed. “It wouldn’t seem scary.”
But pampering abortion patients is, in many ways, a revolutionary act. It sends the message that they deserve to be treated well. It challenges the idea that there’s something wrong with abortion, and rejects the notion that women need to suffer through some form of penance for choosing to to end an unwanted pregnancy. In turn, Carafem inspires a strong reaction among the anti-abortion community. Right-wing outlets have been offended by the organization’s approach to the procedure, which they describe as “nauseating.”
Carafem is explicit about its strategy, saying on its website that it is “on a mission to update the experience and modernize the conversation around abortion.” The organization extends this approach beyond the four walls of its clinic. This year, it ran a series of advertising campaigns on D.C. public transportation featuring an unapologetic tone: “Abortion? Yeah, we do that. Birth control? Yeah, we do that too.” Using the word “abortion” so plainly still makes a bold statement, Grant said, which helps Carafem make a splash among potential clients.
“We wanted to talk about abortion and birth control in a normal way. We wanted to bring these conversations out into the public,” Postal said. “This is a medical service — so we’re advertising like any other medical provider.”
Less than a year into its practice, Carafem has no plans of slowing down. Grant said her team is “looking with an eye toward expansion” and thinking about opening additional centers in other states. There’s evidence of hunger for its services: Data collected over the past several months shows that clients from all demographic groups are traveling from across D.C., Maryland, Virginia, West Virginia, and even Ohio to make appointments at Carafem. About 5 percent of its patients travel more than 100 miles to get there.
And despite an approach that may evoke high-end spa services typically reserved for the wealthy, Carafem doesn’t want to be a luxury service. As part of its overall mission, the organization wants to address the financial hurdles that often stand in low-income patients’ way. Carafem charges a flat rate of $400 for its abortion pill services — which is about $100 cheaper than other clinics in the area — and offers emergency contraception at a third of the price it goes for in pharmacies. The health center accepts several insurance plans, including Maryland’s Medicaid program, and will try to raise funds for uninsured patients who need additional assistance.
But expanding access to the abortion pill in America — particularly through independent abortion clinics dedicated to demedicalizing the experience — is easier said than done.
“Carafem joins a tradition that has really flowed from some of the best independent provider clinics in the country of really working to destigmatize the procedure and welcome people into a warm environment,” said Amy Hagstrom Miller, the founder of Whole Woman’s Health, a network of eight clinics across five different states. “But our opposition is increasing the stigma and the shame associated with the procedure under the guise of safety.”
Hagstrom Miller, who leads national trainings about how to make abortion clinics more welcoming places, has carefully curated the environment in her health centers. Whole Woman’s Health has always invested in features like wood floors, soft lighting, scented candles, fleece blankets, and cheerful paint colors. Each purple-hued exam room is named after a famous woman — Frida Kahlo, Audre Lorde, Margaret Cho — and features feminist quotes scrawled across the walls. The organization even created a special brand of tea that patients can drink after their abortion procedures to help ease cramping.
However, Hagstrom Miller’s model is under attack in Texas, where harsh restrictions on the abortion procedure don’t leave much room for warm or welcoming health centers. Texas’ law, which will come before the Supreme Court this year, requires abortion clinics to have hospital-like facilities in line with the standards for “ambulatory surgical centers” (ASCs).
CREDIT: Courtesy of Whole Woman’s Health
In order to qualify as an ASC, clinics must incorporate the same features typically found in emergency rooms, such as harsh overhead lighting and hallways that are wide enough to fit a stretcher. Bringing their buildings up to ASC code would require the abortion providers in the state to spend millions of dollars to make unnecessary upgrades, like installing sophisticated air filtration systems and expanding janitor’s closets. It isn’t feasible for most of them; the majority of health centers would simply be forced to close.
Hagstrom Miller runs one clinic in the Lone Star State that would be allowed to remain open under the law because it currently meets the standards for a surgical center. But it has a very different environment than her other cozy health centers. The lamps and the fleece blankets are gone. The tea is gone, too, since she isn’t allowed to serve hot beverages in what’s called the “post anesthesia care unit.” She can’t hang any pictures on the wall.
“It does feel like sort of a mini hospital. It’s quite a bit more sterile,” said Hagstrom Miller, noting that Texas’ new law “does away with the doctor’s office or small community clinic possibility completely.”
“In my view, that’s very much by design and not by default,” she continued. “They’re trying to make abortion seem really complicated and like it needs to be done like a major surgery. These regulations serve to increase people’s thinking that it’s scary.”
Texas is the most dramatic example, but it’s hardly alone. Twenty-two states in total impose onerous licensing requirements on abortion clinics that require them to bring their facilities in line with surgical centers. Depending how the Supreme Court rules on the Texas case — in which Whole Women’s Health is serving as the lead plaintiff — this type of state law may be upheld as constitutional, giving more lawmakers the cover to require abortion clinics to be cold, sterile, and few and far between.
Grant conceded that abortion providers in the United States have been fighting to stay open for years amid mounting attacks and restrictions. Still, she said she remains hopeful about continuing to break down patients’ barriers to abortion access — starting with stigma.
Carafem’s health center is filled with subtle reminders about the societal shift that Grant and her colleagues are pursuing. For instance, there aren’t any photographs of tearful or anxious women, a departure from the most common images used to represent the experience of unintended pregnancy. The women at Carafem are smiling.
“The visit itself is one of empowerment, and we want to reflect that,” Grant said.