In Rural America, the Right to Choose is Only Half the Battle

s.e.smith February 22, 2017

January 23, 1973—The front page of the New York Times one day after the U.S. Supreme Court decided Roe v. Wade.

If the cul­ture wars drove the 2016 elec­tion and its out­come, one of the most obvi­ous wedge issues deployed by the right was abor­tion. The ques­tion of whether peo­ple who are preg­nant should be allowed to exer­cise the right to make a pri­vate med­ical deci­sion should have been set­tled in 1973 with Roe v. Wade, but in fact, the land­mark Supreme Court deci­sion just served to mobi­lize the right and politi­cize the sub­ject of abor­tion to an extreme degree.

On one side: Peo­ple like Pres­i­dent Don­ald Trump, who remarked in a 2016 town hall that he believed women should be pun­ished” for get­ting abor­tions and vowed to appoint an anti-choice Supreme Court jus­tice. On the oth­er: The 79 per­cent of Amer­i­cans who have affirmed that they believe patients should have the right to choose in all or some circumstances.

Some­where in the silent mid­dle: rur­al America. 

Abor­tion is an issue that mat­ters acute­ly to rur­al Amer­i­ca, where it is sub­stan­tial­ly more dif­fi­cult to access repro­duc­tive health care, includ­ing preg­nan­cy ter­mi­na­tions. Rur­al teens in par­tic­u­lar are more like­ly to expe­ri­ence unin­tend­ed preg­nan­cies, accord­ing to CDC data. The issues rur­al Amer­i­cans face when it comes to receiv­ing safe, com­pas­sion­ate abor­tion ser­vices are often elid­ed in the vicious debate over the right to choose in Amer­i­ca, in part because of erro­neous assump­tions about the social and polit­i­cal make­up of rur­al communities.

In 2015, approx­i­mate­ly 14 per­cent of Amer­i­cans lived in non-metro coun­ties,” accord­ing to USDA account­ing. A 2000 sur­vey con­duct­ed by the Guttmach­er Insti­tute found that 97 per­cent of those coun­ties lacked an abor­tion provider (a hos­pi­tal, clin­ic or physi­cian’s office offer­ing abor­tion ser­vices) — and almost none had a provider offer­ing more than 400 pro­ce­dures annu­al­ly. These data are slight­ly out­dat­ed, but the over­all trend of clin­ic clo­sures in the Unit­ed States, espe­cial­ly in pre­dom­i­nant­ly con­ser­v­a­tive and often heav­i­ly rur­al states, means that con­tem­po­rary num­bers may be even more dire.

The Amer­i­can Col­lege of Obste­tri­cians and Gyne­col­o­gists acknowl­edges that the num­ber of care providers in a vari­ety of spe­cial­ties, includ­ing repro­duc­tive health, is declin­ing in rur­al areas. Indeed, 77 per­cent of rur­al coun­ties have been deemed health pro­fes­sion­al short­age areas.” ACOG and the Nation­al Con­fer­ence of State Leg­is­la­tures note that health care out­comes tend to be poor­er in rur­al coun­ties, which are home to close to 23 per­cent of all Amer­i­can women over 18. And while 83.5 per­cent of those women were white in 2014, ACOG found that the num­ber of women of col­or was rapid­ly rising.

Eighty rur­al hos­pi­tals have shut down nation­wide since 2010. A new study finds 650 rur­al hos­pi­tals, in 42 states, are vul­ner­a­ble to clo­sure because they can­not sus­tain oper­at­ing costs. (Info­graph­ic: The Cecil G. Sheps Cen­ter for Health Ser­vices Research)

A provider is a hos­pi­tal, clin­ic or physi­cian’s office where abor­tions are per­formed. A clin­ic is a non-hos­pi­tal facil­i­ty that report­ed 400 or more abor­tions a year, includ­ing abor­tion clin­ics and non-spe­cial­ized clin­ics. For addi­tion­al infor­ma­tion see: Abor­tion Inci­dence and Ser­vice Avail­abil­i­ty in the Unit­ed States, 2014. (Info­graph­ic: guttmach​er​.org)

Dis­tance, access, stig­ma and cost

Access­ing abor­tion in rur­al Amer­i­ca becomes a com­pli­cat­ed tech­ni­cal dance stymied by issues like trav­el, bur­den­some reg­u­la­tions and a hos­tile social envi­ron­ment. The pic­ture of what it looks like to get an abor­tion in a rur­al com­mu­ni­ty doesn’t start with cross­ing a pick­et line of scream­ing pro­test­ers — it often begins miles away, with 31 per­cent of rur­al patients trav­el­ing an aver­age of 100 miles to access abor­tion ser­vices and 43 per­cent trav­el­ing between 50 and 100. For rur­al peo­ple, this makes access more expen­sive, as pub­lic tran­sit can be scarce in rur­al areas, and that means dri­ving, some­times in a bor­rowed or rent­ed vehicle. 

Niko­las Grif­fith, the Inter­im Exec­u­tive Direc­tor of NAR­AL Pro-Choice Mon­tana, relat­ed the sto­ry of one patient from an urban area in cen­tral Mon­tana who had to make the 12-hour dri­ve to Seat­tle to access abor­tion ser­vices. The few clin­ics in Mon­tana are so heav­i­ly booked, he says, that even peo­ple in posi­tions of socioe­co­nom­ic priv­i­lege have to cross state lines for care, which bodes ill for low-income rur­al patients. Those need­ing spe­cial­ized ser­vices like abor­tions lat­er in preg­nan­cy are more like­ly to trav­el fur­ther, and some, says Kelsea McLain, an abor­tion advo­cate in North Car­oli­na, time out” — they run out of time to access a legal abor­tion. Grif­fith com­ments that patients may need to take two to three days to get an abor­tion, which can cause expens­es to balloon.

One of the bar­ri­ers to abor­tion access beyond the lack of a near­by clin­ic is cost. The medi­an price for a sur­gi­cal abor­tion at 10 weeks in 2012 was $495, while a non­in­va­sive med­ica­tion abor­tion using a com­bi­na­tion of mifepri­s­tone and miso­pros­tol costs $500, accord­ing to the Guttmach­er Insti­tute, an inter­na­tion­al fer­til­i­ty and repro­duc­tive health research orga­ni­za­tion. For those trav­el­ing great dis­tances, lodg­ing and food expens­es can also become a con­cern, turn­ing $500 into much more. These pro­ce­dures become more expen­sive lat­er in preg­nan­cy, and also more cost­ly when a facil­i­ty doesn’t per­form very many abor­tions. Both of these com­pli­cat­ing fac­tors are more com­mon in rur­al Amer­i­ca where around 18 per­cent of peo­ple live in poverty.

For addi­tion­al pover­ty infor­ma­tion and high res­o­lu­tion info­graph­ics from the USDA’s Eco­nom­ic Research Ser­vice, click here.

The reg­u­la­to­ry cli­mate has also served to catch rur­al Amer­i­cans in a vicious trap, start­ing with restric­tions on the use of gov­ern­ment funds for abor­tion ser­vices. Low-income rur­al patients can­not use Med­ic­aid fund­ing for abor­tion, and while some states reserve their own pri­vate, non-fed­er­al fund­ing for abor­tion ser­vices, most do not. For those receiv­ing cov­er­age under Afford­able Care Act plans, the Kaiser Fam­i­ly Foun­da­tion found that some states explic­it­ly ban mar­ket­place plans — those pur­chased by low-income Amer­i­cans — from cov­er­ing abor­tion, or allow it only under lim­it­ed circumstances.

Many con­ser­v­a­tive states have also enact­ed, or attempt­ed to, a host of reg­u­la­tion designed to restrict abor­tion access, includ­ing: parental noti­fi­ca­tion; tar­get­ed reg­u­la­tion of abor­tion providers; manda­to­ry coun­sel­ing; wait­ing peri­ods; manda­to­ry ultra­sounds; fetal remains dis­po­si­tion laws; and reli­gious con­science” laws. Some have suc­ceed­ed in reg­u­lat­ing clin­ics almost out of exis­tence, forc­ing patients to cross state lines if they want to access safe abor­tions in a clin­i­cal setting.

But these efforts often car­ry an extra sting for rur­al patients. Longer wait­ing peri­ods, in addi­tion to trav­el time, require many patients to take more time off from work than they can afford, with some cit­ing lost wages” as an abor­tion issue in a 2013 Women’s Health Issues study. McLain relates that wait­ing peri­od laws in par­tic­u­lar can be crush­ing for rur­al patients, who may miss a phone coun­sel­ing appoint­ment, trav­el to the clin­ic, and then dis­cov­er that they can’t receive their pro­ce­dures. Bur­den­some reg­u­la­tion may push patients to delay abor­tion pro­ce­dures, which can make them more cost­ly or put them in con­flict with 20 week bans.

Even in states with fair­ly per­mis­sive abor­tion laws, rur­al coun­ties strug­gle to access care, and this gets more com­pli­cat­ed in red states. In Mon­tana, Grif­fith and his col­league Caitlin Car­roll note that a fero­cious­ly pro-choice gov­er­nor and enshrined right to pri­va­cy in the state con­sti­tu­tion are a bul­wark when the leg­is­la­ture explores ways to lim­it access. But it’s a frag­ile one — the lim­it­ed num­ber of clin­ics in the state is a huge bar­ri­er to access, and fund­ing threats to Planned Par­ent­hood and Med­ic­aid are a loom­ing concern.

New leg­is­la­tion, pub­lic aware­ness and telemedicine

One pos­si­ble solu­tion to the prob­lem of rur­al abor­tion access may lie in the scope of prac­tice laws dis­cussed above, which McLain says would be real­ly help­ful.” In Cal­i­for­nia, nurse prac­ti­tion­ers, cer­ti­fied nurse mid­wives, and physi­cian assis­tants are allowed to per­form both med­ical and sur­gi­cal abor­tions after com­plet­ing spe­cial­ized train­ing. A Hawai­ian law­mak­er just intro­duced a sim­i­lar bill, and sev­er­al oth­er states allow non-physi­cians to per­form abortions.

Grif­fith relates that the Mon­tana leg­is­la­ture has point­ed­ly attacked anoth­er pos­si­ble solu­tion, telemed­i­cine, which allows patients to receive med­ical abor­tions remote­ly, with a doc­tor pro­vid­ing video coun­sel­ing for a patient who receives med­ica­tion at a rur­al clin­ic. In Iowa, the avail­abil­i­ty of telemed­i­cine abor­tion cre­at­ed a clear sea change in the abor­tion land­scape: Even as abor­tions fell in line with nation­al trends, more patients received med­ical abor­tions, more patients received treat­ment pri­or to 13 weeks and more patients in far-flung areas were able to access abor­tions. Research in Alas­ka also high­light­ed the increased access it offered to rur­al patients. ACOG sup­ports telemed­i­cine abor­tion, call­ing it safe and effec­tive,” and it’s been a suc­cess in Maine and Min­neso­ta. Maine, with a high­ly rur­al pop­u­la­tion, is per­haps the best illus­tra­tor of the ben­e­fits of telemed­i­cine options. Eigh­teen states, how­ev­er, have moved to ban it or lim­it access, accord­ing to Rewire, with laws requir­ing a doc­tor to be present to supervise.

The work of peo­ple like Grif­fith, Car­roll, and McLain high­lights the fact that in rur­al Amer­i­ca, peo­ple have been fight­ing to pro­tect abor­tion access for a very long time, includ­ing in red states. They’re advo­cat­ing with leg­is­la­tures, pro­vid­ing abor­tion refer­ral ser­vices, run­ning abor­tion funds and doing pub­lic out­reach. They’re often unseen, says Grif­fith, who notes that a grow­ing aware­ness of these issues after the elec­tion led many to real­ize how much work peo­ple were doing behind the scenes.

Our goal,” Grif­fith jokes, is to put our­selves out of a job.” He may want to hold off on mak­ing any major retire­ment plans just yet. 

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s.e.smith is an essay­ist, jour­nal­ist, and activist is on social issues, with cred­its in pub­li­ca­tions like The Guardian, Bitch Mag­a­zine, Alter­Net, Jezebel, Salon, the Sun­dance Chan­nel blog, Long­shot Mag­a­zine, Glob­al Com­ment, Think Progress, xoJane, Truthout, Time, Nerve, VICE, The Week, and Rewire. Fol­low @sesmithwrites .
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