This editorial was written by Ushma Upadhyay, PhD, MPH, and originally published in AJPH.
In 2013, we published one of the first articles from the Turnaway Study, in which we estimated that 4,000 pregnant people were denied an abortion each year because they presented for care beyond the facility’s gestational limit (see p. 1305 of this issue). We found the most common reasons for being delayed in seeking an abortion were having to raise money for travel and procedure costs and not recognizing the pregnancy earlier.
Barriers Expected to Increase
On June 24, 2022, the US Supreme Court officially reversed the 1973 Roe v. Wade ruling, declaring that the constitutional right to abortion no longer exists. This decision allows states to ban abortion at any point in pregnancy or altogether. In April 2013, when our Turnaway article was published, seven states banned abortion at 22 weeks, and one state banned abortion at 20 weeks.
This year, up to half of states could ban abortion altogether, and about 100,000 people will be essentially “turned away” from receiving care in their own states, leaving them to seek this essential health care service in other states. It is projected that only one fourth of people needing abortion care will be able to travel out of state. For the rest, travel and procedure costs and other logistical barriers will be insurmountable—particularly for people with disabilities, adolescents, incarcerated people, immigrants, those with young children, and those living on low incomes.
Legal, Distance, and Cost Barriers Are Often Insurmountable
By increasing the hurdles to getting an abortion, people are pushed into seeking abortion care later in pregnancy (p. 1297). In our recent prospective study, pregnant people considering abortion living 50 miles or more from the closest abortion facility were significantly more likely to still be pregnant and either resigned to continuing the pregnancy or still seeking an abortion 4 weeks later.
Raising the funds to pay for an abortion can lead to further delays and create a cycle of increasing cost and delay. One Turnaway participant explained why she could not go to another clinic after being denied an abortion at first: “It was probably travel costs, procedure costs, not knowing who I would have to come with me on the 4-day adventure. I was at the point that there was no guarantee wherever I went.”
The number of facilities that offer later abortion care has been declining. Although the total number of facilities increased over 2017 to 2021, the regions with fewer facilities experienced even more clinic loss. Before the Supreme Court decision, the United States had 790 publicly advertising abortion facilities, and only 17% (137) offered care after 20 weeks of pregnancy. As states continue to ban abortion, we expect that only 104 facilities nationwide will offer abortion care after 20 weeks of pregnancy, with the vast majority in the Northeast and West.
Self-Managed Abortion is Fraught with Legal Risk
Some pregnant people who want an abortion but cannot travel will attempt to self-manage their abortions. In 2013, abortion medications mifepristone and misoprostol were not as easily available. Today, we have virtual abortion facilities that offer abortion care through telehealth and mail in the 21 states where it is legal. We also have online sites, such as Aid Access, that will mail abortion medications to patients even in states that ban abortion or delivery of medication by mail. However, these medications are most effective when used in the first 11 weeks of pregnancy. The medications ship from abroad and can take up to two weeks to arrive, delaying care. This approach also subjects pregnant people, particularly people of color whose behavior is more often monitored, to risk of criminalization. Given how safe abortion pills are, people can use them on their own. But people have a right to the care and comfort that comes from having a provider support them, regardless of their state of residence.