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In a 6 to 3 decision on June 24, 2022, the U.S. Supreme Court voted to overturn Roe v. Wade, reversing the court's 50-year-old decision that guaranteed a woman's right to obtain an abortion. The court's action also set off trigger laws that banned or severely restricted abortions in some states and prompted protests across the country.

Access to abortion fraught with more logistical challenges as patients confront increased restrictions

“I don't know how I'm gonna afford this.” 

“I don't know how I'm gonna find a babysitter. Who's gonna take care of my kids?” 

“My car is not running well.”

Kell Rippy said they frequently hear patients express these challenges and a list of others while working as a patient navigator at Planned Parenthood South Atlantic. Rippy’s job is to help abortion seekers sort through logistical challenges to care, whether in their home state or if they need to seek care in another state.

Since North Carolina’s increased abortion restrictions took effect July 1, imposing additional hurdles to accessing abortions, Rippy said that work has picked up. The Guttmacher Institute, a national organization that’s long tracked trends in reproductive health, says significantly fewer abortions have been provided in North Carolina.

The new state law limits most abortions after 12 weeks of pregnancy and requires two in-person appointments for anyone seeking an abortion. This means many patients need to drive long distances — now twice — to reach one of the state’s 14 abortion clinics spread over nine counties. Others must journey out of state for care later in pregnancy. It necessitates extra time off work, travel, hotel stays and child care costs.

“That's really, really stressful, especially for folks who are low income or who are already working to make ends meet,” Rippy said.

Navigating care

Accessing abortion can quickly feel overwhelming for patients, Rippy said — even insurmountable.

That’s where Rippy steps in as part of the patient navigation team at Planned Parenthood South Atlantic. Rippy and one other patient navigator make dozens of calls every week, working with patients to try to find ways around barriers to abortion care.

“I have a master's degree [in health care],” Rippy said. “If I'm having a hard time figuring it out, then patients have got it even worse — especially if they have low health literacy, which a lot of our country does.”

The patient navigators have established connections with local partners as well as clinics and support networks across the country. They’ve accumulated a wide knowledge of public transportation options, knowing essentially where every bus station on the East Coast is. They’ve created guides that can help people seeking out-of-state care navigate frequently visited cities like Roanoke, Virginia.

Though Planned Parenthood has seen fewer patients in recent months, they said the amount of time spent with patients has dramatically increased, including working through coordination of appointments and travel arrangements.

A Planned Parenthood waiting room that shows empty chair in a medical building
A Planned Parenthood health center waiting room.

And despite best efforts to keep abortion accessible to those who seek it, Rippy knows some people are falling through the cracks, unable to overcome logistical hurdles.

“The hardest thing for me is knowing the number of patients that we are able to help is only a fraction of the number of patients that actually need the help,” Rippy said. “There are some people who are able to get through to us who are able to go online and make an appointment. Then there are some people who have no idea where to even start. They live in Mississippi, and it's like, ‘Okay, well, abortion is illegal in my state. So I guess I'm screwed, right?’ … I think about the people that we’re not able to help that would greatly benefit from the care.”

Biggest barrier

One of the biggest barriers to abortion access is cost, said Justine, a Carolina Abortion Fund staff member, who requested that NC Health News only use her first name for security reasons. 

Carolina Abortion Fund exists to fill funding gaps, helping patients pay for part of their procedure, and demand keeps growing.

Justine said calls for financial help surged after the Dobbs decision, and it has bumped up even further since North Carolina increased restrictions. In addition to more people calling, Justine said they are also often requesting more money than in the past. 

The cost of an abortion varies based on factors like how far along someone is in their pregnancy, the location of the procedure and how much their insurance will cover.

In 2021, the median costs for people paying out of pocket in the first trimester were $568 for a medication abortion and $625 for a procedural abortion — an amount people may not have on hand for unexpected expenses. 

Nonmedical costs for gas, flights, hotels, child care and lost wages also accumulate. Particularly in the increasingly restrictive landscape of abortion access, where people often have to travel farther distances for care, Justine said she’s seen the tally of costs swell for folks. 

“All of it kind of snowballs together,” Justine said.  

Justine estimated that about 80 percent of callers are asking for money to cover practical support to get to their appointments: things such as gas, flights and child care. That’s an uptick from before North Carolina’s law took effect, she said, when about half of folks expressed that need. Although Carolina Abortion Fund does not collect data on where callers are traveling from, Justine said the bigger requests for practical support indicate that people are traveling farther for care.

In response, Carolina Abortion Fund’s allocations per caller have gone up since July 1. On average, Carolina Abortion Fund provided around $175 per caller before July, and now that number is around $300 per caller, though each recipient’s amount is based on their specific situation.

The organization's total distribution of funds has also surged. Since June, Carolina Abortion Fund has distributed around $65,000 per month to callers — nearly double the amount disbursed in earlier months.

Justine said the organization’s available funding isn't enough to meet the flood of requests.

“Each month, we unfortunately have to close the line, and it does feel like we're reaching that point earlier than we did prior to the law,” Justine said.

After Carolina Abortion Fund reaches the point each month where it has no more money to give out, volunteers and staff members still work with callers to help figure out funding, referring them to other funds and resources.

“This is a need that's been around for so long, and the calls don't change depending on who's in office and what laws are on the books,” Justine said. “Things can just be made more difficult for people.”

Crossing state lines

Traveling across state lines for abortion has doubled in recent years, largely due to post-Dobbs abortion bans and restrictions. During the first half of 2023, nearly one in five patients traveled to another state to obtain abortion care, compared with one in 10 in 2020, according to the latest data from the Guttmacher Institute’s Monthly Abortion Provision Study.

In the wake of the Dobbs decision in June 2022, North Carolina experienced a surge of patients coming from other states with more restrictive laws, making the state a hub of access in the Southeast. During the first half of 2023 — before North Carolina implemented its stricter abortion law — about 36 percent of patients traveled from out of state to receive care in North Carolina. This amounted to 8,920 out-of-state patients finding care in North Carolina — a substantial increase from the 2,730 out-of-state patients in 2020.

But with this year’s legislation, North Carolina is no longer the abortion destination it once was. As a result, Guttmacher data scientist Isaac Maddow-Zimet said it's likely the number of people coming to North Carolina for care from other states has declined fairly precipitously in the second half of the year as folks bypass the state for places with fewer restrictions, such as Virginia and Maryland. 

For some folks, though, North Carolina may still be the best option, such as for South Carolinians who have a six-week ban in effect

After North Carolina’s restrictions took effect, the number of medication and procedural abortions provided in the state dropped by 31 percent in July. The latest data released this week by the Guttmacher Institute shows September abortion volume inching higher, but still down 15 percent from June.

Maddow-Zimet cautioned considering the September bump in volume a rebound in access for North Carolinians; he said it’s likely many of the around 600 more abortions provided in September in North Carolina were due to an influx of South Carolinians.

“It may have become again kind of the best of a buffet of bad options for folks trying to access care,” Maddow-Zimet said.

Rippy, the Planned Parenthood patient navigator, said before Senate Bill 20, it was rare for North Carolinians to need to seek care out of state as the procedure was allowed up to 20 weeks of pregnancy. Now, cases come up every week where North Carolinians can’t receive care close to home, Rippy said. 

Maddow-Zimet said practical support efforts have facilitated the increase in interstate travel, but he’s uncertain that the rate of travel can continue.

“It's tricky to know whether that will be sustainable” as options narrow in the Southeast, Maddow-Zimet said. “Part of the reason is because each additional ban that passes has cumulative effects on what came before it.”

This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.

North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.