Abortion Any Time Isn’t Just a Rallying Cry—It’s True Reproductive Freedom

Abortion Any Time Isn’t Just a Rallying Cry—It’s True Reproductive Freedom

Abortion Any Time Isn’t Just a Rallying Cry—It’s True Reproductive Freedom

A year after the fall of Roe, affordable, meaningful access to abortion throughout pregnancy remains an indispensable goal of reproductive justice for all.

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In November 2022, Anne Angus and her husband packed their two Australian shepherds in their car and drove about 10 hours from Montana to Colorado for an abortion. Not two months had passed since Angus had quit her job to be a stay-at-home mom. But her 20-week anatomy scan showed some concerning results, and she was referred to Children’s Hospital Colorado, in Denver, for follow-up testing. She had to wait three weeks for that appointment.

After giving her a battery of tests, the care team at Children’s Hospital Colorado told her that the baby would have prune belly syndrome, a rare condition that is sometimes rapidly fatal, sometimes not, but always medically complex. She would need to move to Denver a month before her due date and stay there for as long as it took to get through multiple rounds of surgery on the baby, which would almost certainly include kidney transplants and other major surgeries, with no clear prognosis. “I felt like even then they were laying out the best-case scenario,” Angus said. No one on the care team presented abortion as an option—and because it wasn’t brought up, she didn’t ask about it. “It felt like it would be a taboo, shameful thing to ask these professionals who are telling me how I can save my baby,” she said.

After meeting with the care team, Angus spoke to her husband. His experience caring for a close relative with complex medical needs helped them decide abortion was the right choice for their family. She contacted the high-risk obstetrician on the team and asked for a referral. He told her to call the Boulder Abortion Clinic. But Angus would have to wait two weeks for that appointment. By then, she’d be 26 weeks pregnant. She would also have to clean out her savings for the $8,000 procedure, which her insurance would not cover.

While she waited to return to Colorado, Angus settled into what she calls “limbo land.” When she finally got to the clinic for her appointment, Angus recalled, she saw that there were notebooks in the waiting room where patients could write their stories. “I realized, ‘Wow, there’s so many, many patients that have come in here with my story,’” she said.

Having to travel out of state for abortion care is becoming ever more common since the Supreme Court overturned Roe v. Wade last summer, ending the national right to abortion. Although the 1973 ruling included some restrictions (allowing states to regulate abortion after “viability,” when they would have an “important and legitimate interest in protecting the potentiality of human life”), and though the 1992 Planned Parenthood v. Casey decision threw out the trimester framework used to consider viability in Roe (allowing states to regulate abortion earlier as medical technology advanced), the Dobbs v. Jackson Women’s Health Organization ruling overturned those decisions and expanded the state’s “interest” in protecting potential life to include the entire pregnancy. In other words, the court went from allowing states to intervene in abortions when they determine that a fetus may, with extraordinary medical intervention, survive outside the uterus—which was when the court believed the states had an interest in “fetal life,” without clearly explaining why that interest was valid—to permitting states to intervene at any stage of pregnancy. Consequently, abortion providers stopped offering care in states where total bans have taken effect, and those seeking care are now being shunted onto waiting lists in an overloaded system.

That abortion care system had already lost 35 percent of its independent clinics in the decade before Dobbs. Today, 13 clinics in eight states and Washington, D.C., offer care up to 24 weeks from the patient’s last menstrual period, according to the Later Abortion Initiative by Ibis Reproductive Health. Three offer care past 28 weeks: the DuPont Clinic in D.C.; Partners in Abortion Care in College Park, Md.; and the Boulder Abortion Clinic in Boulder, Colo. A handful of others, like Seattle’s All Women’s Care, go beyond 24 weeks, but only on a case-by-case basis.

This shortage of clinics is only the most obvious barrier to the provision of all-trimester abortion care. Abortion restrictions even in pro-choice states, as well as broken funding structures, the conservatism of hospitals, and general confusion about what, in fact, constitutes a “later abortion” and how many there are, combine to hamstring access to abortion care throughout a pregnancy. The circumstances that lead someone to need a later abortion encompass the breadth of the human experience. One thing, however, is certain: A society that guarantees access to abortions during all trimesters is one that trusts that the pregnant person—not the church, the state, or the medical establishment—is the only person with an “important and legitimate interest” in the fetal life they carry. One year after the fall of Roe, The Nation spoke to advocates, clinicians, researchers, and policy-makers about the current landscape of later abortion care, as well as what can be done to improve it.

As a growing number of people seek out-of-state abortion care, clinics that once saw four to six patients a week are now seeing 13 to 16, and the three “last stop” clinics that see people after 28 weeks have waiting lists of two to three weeks. Yet increasing the number of clinics offering care after 24 weeks can feel like an impossible feat when even pro-choice groups and progressive lawmakers are using later abortion care as a bargaining chip in the struggle to secure abortion access. Michigan, New York, Connecticut, Illinois, Washington, and Massachusetts have all passed abortion protection bills in recent years; all, however, contain a ban on abortion after viability.

Erika Christensen, codirector of Patient Forward, the only advocacy group dedicated to later abortion care, explained that national reproductive rights groups routinely stress the rarity of later abortion in their messaging, and then often publicly support abortion legislation with a viability ban. “It’s the one-two punch,” Christensen said. “First, here is our proactive policy effort that explicitly cuts people off from legal access to third-trimester care, but don’t worry, because it doesn’t affect anyone anyway.”

For example, a ballot initiative that passed in Michigan last year contained an explicit viability ban. It allows state lawmakers “to regulate abortion after fetal viability, but not prohibit [it] if medically needed to protect a patient’s life or physical or mental health.” Abundant evidence shows that these medical exceptions do not function as intended in practice. Yet national groups like Planned Parenthood and NARAL celebrated the win as absolute. When asked for comment on the Michigan ban, the NARAL spokesperson replied, “Where we start doesn’t need to be where we end.” The Planned Parenthood representative said, “While we understand viability limits are arbitrary, we recognize that existing laws and political climates vary among states.” Both groups pointed to efforts they have supported to lift viability bans in states like Vermont.

Meanwhile, research on why patients seek later abortions has just scratched the surface. Katrina Kimport, a professor at the University of California, San Francisco, and one of the few researchers on abortion after 24 weeks, divides later abortion seekers into two groups: those who wanted care earlier and could not get it because of factors like bans or an inability to travel, and those who discovered new information about the pregnancy. After Roe’s fall, the numbers in the former group are already on the rise.

For decades, the oft-repeated line about abortion after 24 weeks has been that it is vanishingly rare, representing fewer than 1 percent of total abortions per year. But a team of scientists at the University of Colorado Boulder headed by the sociologist Amanda Stevenson now believes that it was greater than 1 percent before Dobbs. “Even before Dobbs, no one really knew how many later abortions happened,” said Leslie Root, a postdoctoral research associate in Stevenson’s lab. Stevenson and Root decided to find out.

Stevenson’s team started by examining what was happening in their home state. They discovered that official counts of post-24-week care were distorted by the stigma associated with abortion. “We heard from providers [at hospitals and clinics] that they thought they weren’t supposed to report procedures or indications related to the fetus as abortions,” Stevenson said. “There was no guidance to that effect coming from the [Colorado] public health department, but that’s what they believed they had heard. But no one could say where they’d heard it, or when.” As a result, the number of later abortions, at least in Colorado, have been undercounted.

Stevenson’s team is still in the early stages of their project. “There is a concern that this research will create more of a target on later providers if the number of later abortions is known,” Root said. However, patient advocates and practical support groups have stressed that the risks of collecting the data are worth it if it might help reduce the stigma of later abortion and improve patient care in the states where it is available.

As researchers work to paint a clearer picture of later abortion in the United States, providers in states where it is legal are attempting to expand access to it, within the confines of systemic legal, financial, and logistical barriers to all-trimester abortion care. Dr. Meera Shah, the chief medical officer of Planned Parenthood Hudson Peconic (PPHP) in upstate New York, is responsible for the standards of care at 10 clinics. Abortion is legal up to 24 weeks in New York State, after which it is banned, with some exceptions. But nearly all of the providers in the state that offer care up to that point are in New York City, meaning people must travel from as far as Buffalo in order to access later care in the state. “Patients have jobs. They have families,” Shah said. “It’s hard for them to get into the city.”

PPHP provides care only up to 17 weeks, six days—like many other Planned Parenthood clinics in the country, it does not provide abortions up to the legal limit of care in the state—but Shah is trying to change that. “I just hired an assistant medical director who performs abortion care up to 24 weeks,” she said.

She plans to roll out that care in the next few months, but regulatory burdens remain. For example, New York State requires clinics to partner with a funeral home to dispose of remains from abortions after 20 weeks. “Very few patients want that up to 24 weeks,” Shah said, “and it’s an extra expense,” in some cases $1,000 or more. Shah also wants to increase the level of sedation she is currently able to offer, but it takes time to receive the regulatory approval. Once she has it, she might be able to turn a two-day appointment for a 24-week abortion into one day, so patients “can come in pregnant and leave not pregnant.” That would reduce travel time and expenses, making care more accessible.

Another clinic may be opening soon that is specifically geared toward all-trimester care: the Valley Abortion Group, or VAG, the first worker-owned, midwifery-focused abortion clinic led by women of color, which is raising funds to open in Albuquerque. But the larger clinic system remains unstable at best: Dr. LeRoy Carhart, owner of the CARE clinic in Bethesda, Md., died in April, after struggling with a succession plan for years. The clinic is now under new ownership. And Albuquerque’s Southwestern Women’s Options, where Dr. George Tiller’s associates relocated following his assassination in Kansas in 2009, stopped offering third-trimester care in January, when it abruptly laid off its later abortion providers.

All the clinics that offer care after 28 weeks are independent—meaning they are small medical practices, and thus are vulnerable to all the problems that typically affect small businesses, including unexpected closures, succession troubles, and razor-thin profit margins. Despite serving as part of the social safety net, they generally cannot take private insurance or Medicaid and rely on an overloaded, baroque referral and funding model that pushes patients, providers, and funders to the brink.

One day stands out to Morgan Nuzzo, a certified nurse-midwife and co-owner of the Maryland-based Partners in Abortion Care clinic. Purely by coincidence, all of her abortion patients that day were under 15 years old. She remembers the children bickering over who would get a Capri Sun juice pouch and asking when they could go home. Those are the easier days, she said; the worst are when she must turn a child away for being too far along. All of it, she added, is exhausting. But a large part of that exhaustion has to do not with the patients, but with the financial hurdles the clinics face simply to stay open.

Partners in Abortion Care, like many other clinics that provide later abortion care, coordinates with the National Abortion Federation and as many as 32 abortion funds around the country to help cover patient costs. Because the funding comes from a number of sources, it can take months to collect the full fee—and yet during that time, Partners must still make its payroll. “We’ve considered emptying our 401(k)s,” Nuzzo said. At the time this article went to press, Partners had $705,607 in outstanding fees for services rendered. The result is that it often provides thousands of dollars of care each year pro bono. But providers believe there must be a way to streamline patient funding. Erin Grant, the co–executive director of the Abortion Care Network, echoed this sentiment: “We actually need to just give the providers the money to be able to meet the challenges. They serve their community. They know what they need.”

The people who make up the scrappy networks of hotlines, abortion funds, and practical support groups making patient appointments, travel arrangements, and calls to secure funding, meanwhile, all wish that it were easier to navigate the clinic landscape. Because of security concerns, many providers of later abortion care don’t openly advertise the full range of their services. And many hotlines require that patients already have an appointment before they will commit funding, but patients are understandably hesitant to book an appointment that costs $10,000 or more when they don’t know if they’ll be able to pay for it.

Ariella Messing, the director of OARS (Online Abortion Resource Squad), a volunteer-run organization that works with clinics, lawyers, and funds to direct abortion seekers on Reddit to safe care, wishes that more information about pricing, procedures, and appointments could be made available directly to patients. “We need to think about audience. Is your [clinic] landing page written for media, for the movement, or for patients?” she said. She believes that clinics providing second- and third-trimester abortions need much clearer information about price and procedures on their websites. For example, a third-trimester provider that chooses a three-day instead or a four-day procedure should provide a clear explanation of why they chose that procedure.

Once patients have managed to navigate the baling-twine and duct-tape referral system to land on one of the later abortion clinics’ waiting lists, they’re showing up in worse shape than patients before Roe fell, further complicating their support needs. Dr. Benedict Landgren, an ob-gyn who has been providing third-trimester abortions since 2018, recalled one patient with a grave heart condition. “Pre-Dobbs, I would have had her cardiology team coordinating with the clinic,” he said. “Instead, she showed up with some pictures of her records on her phone. Nobody thought it was a good idea for her to continue this pregnancy, but she described it as the most abandoned she’d ever felt by her team.”

Nuzzo and every other provider I spoke with stressed the need for training funds, to ensure that the next generation of providers can continue the work. “It costs a lot to train somebody…. My priority is always APCs [advanced practice clinicians] and nurses,” she said. There are funds available in Maryland, but the administrative burden of figuring out how to access them while juggling everything else has thus far proved to be too high.

That doesn’t even touch the problem of training clinic staff who don’t provide direct abortion care. As Melissa Fowler, the chief program officer at the National Abortion Federation, explained, “There has been a lot of work across the field to ensure a future generation of physicians, but there hasn’t been as much success in creating pipelines for other key roles, like administrators and other clinic leadership positions, that are also essential to ensuring access to care.”

Landgren echoed Nuzzo’s desire to train more providers. “If I ever open my own clinic, I hope to train lots of young physicians. I want to train myself into redundancy as soon as possible,” he said. He sketched out plans for working with a local hospital to have residents do rotations. But to do that, he needs a clinic; the biggest constraint on providing second- and third-trimester abortion care is the lack of brick-and-mortar clinics for providers to work in.

Nuzzo also needs a bigger building. Before it opened last year, Nuzzo told The Nation she thought they had three to five years before they’d need a bigger space. But the demand for care is so great that they’ve outgrown their space in less than six months. “We literally have no more space to put people,” she said. But a new building is easily $1.5 million to $3 million. Nuzzo wishes there was a state-level policy solution so Partners could take out a low-interest mortgage on a new space.

While providers are doing all they can to meet the rising need, they wish it didn’t feel like it was all on them. “Large institutions [like hospitals], when they have been able to provide third-trimester care, have done so only for the most ‘sympathetic’ patients. I’d like to see them practice in a way that is informed by reproductive justice,” Landgren said.

Dr. Deborah Bartz, an associate professor of obstetrics and gynecology at Harvard Medical School who is affiliated with Brigham and Women’s Hospital in Boston, works at one of those “large institutions.” She says that the process of liberalizing abortion policy in hospitals is like turning an ocean liner. “But in a way that doesn’t topple the silverware off the table in the dining room,” she said. “At an individual level, it might not seem fair, as patients do fall through the cracks [with this system],” she said. But she stressed the long-term importance of building a consensus among her colleagues as they try to turn the ship together—and in the meantime, of taking as many second-trimester patients as possible, to save spots at Partners, DuPont, and Boulder.

Today, Anne Angus works for Montana Family Planning, a Title X organization that provides sexual and reproductive health care. She is pursuing IVF for a second child but fears the current legal landscape. “My health wasn’t in immediate danger, but that could easily have changed,” she said, referring to her previous pregnancy. “I really want two children. But depending on how this next pregnancy goes… I might be one-and-done, because I’m not sure the risk [to my life] is worth it.”

Under the current system, Angus’s story is the best-case scenario: She lived within a day’s drive from a later abortion provider, had a car, had relatives in Denver, and could pay out of pocket. But not everyone makes it off the waiting lists. Some patients are sent away and are forced to endure a painful, hours-long labor, only to deliver a baby that will not survive after birth. Meanwhile, patients whose newborns do survive face the prospect of raising a medically complex child in the context of an ineffective health care system. And even if they deliver a healthy baby, they will be raising that child in a country whose social policies are stacked against working families. A year after the fall of Roe, affordable, meaningful access to abortion throughout pregnancy remains an indispensable goal of reproductive justice for all.

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