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Abortion clinics are closing in rural America. So are maternity wards.

In a growing number of reproductive health care deserts, there’s no place to get an abortion — or give birth.

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A pregnant woman in McAllen, Texas in August, 2016.
A pregnant woman in McAllen, Texas in August, 2016.
Anna North is a senior correspondent for Vox, where she covers American family life, work, and education. Previously, she was an editor and writer at the New York Times. She is also the author of three novels, including the New York Times bestseller Outlawed.

The last abortion clinic in Kentucky is fighting to stay open.

A trial that began on Wednesday at a federal court in Louisville will decide whether EMW Women’s Surgical Center can continue to provide abortions. Kentucky’s Republican Gov. Matt Bevin told the clinic in March that its agreement to comply with strict laws targeting abortion clinics was inadequate, according to NPR. The center sued, arguing that the notification came “out of the blue.” If it wins, the case could open the door for other Kentucky clinics to provide abortions. If it loses, the state will become the first one with no place to safely terminate a pregnancy.

The number of abortion clinics nationwide declined 6 percent between 2011 and 2014, with the biggest declines happening in the Midwest and the South, according to the Guttmacher Institute.

Not only are abortion clinics like the one in Kentucky under threat, but a new study shows that hospitals in rural areas throughout the country are eliminating obstetric services, meaning women have to drive for hours to give birth.

The study found that 54 percent of rural counties had no hospital with obstetric services in 2014, up from 45 percent in 2004, according to a recent study published in the journal Health Affairs and reported at ProPublica. That left 2.4 million women of reproductive age living in counties without obstetric care. In Kentucky, where the fight over the last abortion clinic is taking place, only 34.1 percent of rural counties had a hospital with obstetric services, down from 40 percent in 2004.

The Kentucky clinic’s struggle and the study’s findings point to a dual crisis in reproductive health care: Whether a woman wants to continue with her pregnancy or end it, in more and more parts of the country, there’s nobody to help her.

Having to travel long distances for abortion or maternity care is bad for women and families

When the nearest abortion clinic is far away, the costs of the procedure for women go up. In addition to the cost of gas or train or bus tickets, women may have to pay for lodging, especially in states that require multiple clinic visits for abortions. They may also have to take time off work, which can mean lost wages or even a lost job. The need to save money for travel expenses can force women to delay their abortions, making them even more expensive.

When travel becomes prohibitively expensive or difficult, women may try to self-induce an abortion. In Texas, where 96 percent of counties have no abortion provider, between 100,000 and 240,000 women between the ages of 18 and 49 have tried to self-induce an abortion at some point in their lives, according to a 2015 estimate by the Texas Policy Evaluation Project. Depending on the method, self-induction can be dangerous — in a 2014 survey reported by CBS, some women reported getting hit in the stomach in an effort to end a pregnancy.

Having to travel long distances for obstetric care can also be dangerous. Long travel times could contribute to infant mortality and pregnancy complications, according to the Health Affairs study. “All maternal and infant deaths are tragic,” the authors write; “those related to impaired access to care are abhorrent.”

Pregnancy and childbirth come with a number of risks, including hemorrhaging, gestational diabetes, and postpartum depression, said Megan Donovan, a senior policy manager at the Guttmacher Institute. “Access to quality prenatal, labor and delivery, and postpartum care is essential to help identify and avoid these dangers.”

When patients live far away from their obstetricians, prenatal care often has to focus on travel and other logistical planning for the birth, rather than the health of the mother or fetus, said Katy B. Kozhimannil, a professor of health policy and one of the study authors. “There’s a level of anxiety” around giving birth for anyone, she said. Living in a rural area where just getting to the hospital is a struggle only heightens that anxiety.

Why are women losing access to abortion and maternity care?

Some of the biggest drivers of abortion clinic closures are targeted regulation of abortion providers, or TRAP, laws. These laws place restrictions on clinics that do nothing to protect patients. In 11 states, for instance, clinics are required to have a relationship with a local hospital — according to the Guttmacher Institute, such laws do nothing to help patients, but give hospitals “effective veto power over whether an abortion provider can exist.” Kentucky passed such a law in 1998, requiring abortion doctors to have transfer agreements with hospitals; Gov. Bevin now argues that EMW’s transfer agreement is inadequate.

In Whole Woman’s Health v. Hellerstedt, last year, the Supreme Court found that a Texas law requiring that abortion providers have admitting privileges at local hospitals, and that abortion clinics be certified as “ambulatory surgery centers,” constituted “an undue burden on abortion access” and was unconstitutional. The majority opinion, by Justice Stephen Breyer, said that neither provision of the law "offers medical benefits sufficient to justify the burdens upon access that each imposes."

Reproductive rights advocates saw the decision as a serious blow to the TRAP law strategy. The American Civil Liberties Union, which is representing EMW Women’s Surgical Center, believes that the Kentucky law requiring transfer agreements fails to offer benefits that outweigh the burdens it imposes, and thus is unconstitutional by the standard set forth in Hellerstedt.

In rural areas, TRAP laws aren’t the only threat to abortion clinics. Some clinics may close because there simply aren’t enough doctors to staff them, Donovan said. “Abortion, of course, is highly stigmatized and it’s difficult to find providers who are willing to practice, particularly in hostile and sometimes dangerous environments,” she explained. “So you can imagine being isolated in a rural community and being that much more of a target.”

Maternity care in rural areas also faces a number of different threats. “Rural health care in general is particularly vulnerable to reductions in state and federal budgets and workforce supply,” the study authors note — and when hospitals have to cut costs, obstetric care is often the first to go. In places with few births per year, it may not be cost-effective for hospitals to offer maternity care.

Patients giving birth in rural areas are disproportionately likely to be covered by Medicaid, putting rural hospitals in a difficult financial position. Medicaid reimburses for maternity care at about half the rate of private insurance, said Kozhimannil. Any cuts to Medicaid, like those proposed in recent Republican plans to repeal the Affordable Care Act, would have a disproportionate impact on maternity care in rural areas.

It can also be hard for rural areas to recruit and retain obstetricians, said Kozhimannil, since doctors working in underserved areas have to travel long distances and work long hours to take care of patients who have no one else to go to. The more facilities stop offering maternity care, the worse this problem gets.

Abortion and maternity care are closely linked — even if laws try to separate them

“There has long been an assumption that one could separate out issues around abortion from issues around birth,” said Lynn Paltrow, the executive director of National Advocates for Pregnant Women. But, she noted, the majority of women who get abortions already have children. “Any given woman in her lifetime is very likely to need both birth support and abortion,” she explained, and both are becoming less and less available.

That’s especially true in rural areas. “Rural people in general have less and less access to the heath care they need,” Paltrow said.

The Improving Access to Maternity Care Act, which passed in the House of Representatives in January but has yet to get a vote in the Senate, would help address problems with doctor recruitment and retention in rural communities, said Kozhimannil. The bill would allow the federal government to identify areas with shortages of maternity care doctors and place obstetricians and certified nurse midwives in those areas, according to Elissa Strauss at Slate.

In places that have lost maternity care, hospitals, emergency medical services, law enforcement, and others need to plan for the emergency births that will happen when mothers can’t get to a hospital in time, Kozhimannil said. And rural areas can follow the example of programs in Alaska to offer transportation and housing help to women who have to travel to give birth.

Access to contraception and family planning services are especially important in rural areas where both abortion and maternity care providers are far away, Kozhimannil added.

For her, a measure of empathy among policymakers is also crucial. “Most of the people that conduct this research and make these decisions are people that have spent all of their adult lives in urban areas,” she said. “It’s really important for people who make these decisions and policy to think about what it’s like for rural women and families.”

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