PUBLISHED Mar. 7, 2022, at 6:00 AM

Undue Burden

How abortion restrictions have become obstacles for women across the U.S.

Abortion is a constitutional right — at least for now. But for many women, it’s a right that comes with an asterisk.

Under current law, states can’t ban abortion until after a fetus reaches viability, which usually happens around 23 and 24 weeks of pregnancy. Some states don’t have limits on when abortions can happen, but most do — which means women have anywhere from a few weeks to a few months to make their decision and get the procedure.

Those restrictions don’t always seem especially burdensome, at least on their own. An ultrasound, a waiting period, a few hundred dollars — what’s the big deal? But when we talked to women about what their abortions were like, they told us that in real life the restrictions pile on top of each other. They add up in a way that’s expensive, bureaucratic, confusing and exhausting.

Even in states like California, where there are few formal state restrictions, access to abortion can feel threadbare and fragile. And this is what abortion looks like while it’s still a constitutional right. All of these burdens could quickly morph and multiply if the Supreme Court upholds Mississippi’s ban on abortion after 15 weeks later this year.

Trigger ban

Law designed to quickly ban abortion if Roe is overturned

Pre-viability Ban

Law prohibiting abortion before 24 weeks of pregnancy

Four states (FL, MA, NV and PA) ban abortion at 24 weeks; 20 states ban abortion at fetal viability. Data on abortion restrictions is from a Kaiser Family Foundation analysis of Guttmacher Institute data, as of Sept. 1, 2021. Data on trigger and pre-viability bans is from the Guttmacher Institute, as of Oct. 28, 2021.
Sources: Guttmacher Institute, KFF

It makes me feel like even in places like California, we’re feeling confident and preaching to the choir about how abortion should be legal, but nobody thinks about what it means for abortion to be accessible — the human component of how this process actually feels.

–Emily, California


Four weeks or much more

The amount of time a woman has to get an abortion depends a lot on when she finds out she’s pregnant. And this is where the math starts to get complicated. Because it’s very difficult to figure out exactly when conception happened, doctors count the weeks of pregnancy from the first day of a woman’s last menstrual period — which is to say, at least a week and a half before she actually became pregnant.

Using this unintuitive calculation, the earliest a woman can find out she’s pregnant is about four weeks into her pregnancy. That’s happening more and more, thanks to highly sensitive pregnancy tests. But for lots of reasons, most women don’t find out they’re pregnant until they’re further along — particularly if their cycle isn’t regular, they don’t have any pregnancy symptoms or they’ve never been pregnant before. Researchers have found, too, that the later a woman finds out she’s pregnant, the later she tends to have an abortion.

Based on a survey of 956 women who sought an abortion at one of 30 facilities in the U.S. between 2008 and 2010.
Source: Contraception

But knowing how far along the pregnancy is doesn’t matter just because of state-imposed limits. It also affects pretty much everything else about the process, including what kind of abortion a woman can get. A Guttmacher Institute report published last month estimated that more than half (54 percent) of abortions in 2020 happened using medication, up from 39 percent in 2017. Abortion pills are often cheaper and easier to get than surgical abortions since clinics can offer them even if they’re not a surgical facility. But medication abortions are available up to only 10 weeks of pregnancy.

I was probably eight weeks along when I found out. I had a little bit of nausea, morning sickness, but other than that, I didn’t really have any symptoms. I hid it for a few weeks and then I realized, OK, I have to do something. … By that point, a surgical abortion was my only choice. I couldn’t take the pill.

–Heather, Ohio

Abortion is currently legal until at least 22 weeks of pregnancy in almost all states — and some states have no limits on when it can be obtained — but that doesn’t mean every clinic offers abortion up till that point. Medical experts told us that as the second trimester progresses, abortion procedures get more complicated and fewer providers offer them. (Abortions after 21 weeks of pregnancy are extremely rare, and only a small fraction of abortion providers perform them.) Practically speaking, that means that abortion access is even more limited in some places. Mississippi’s lone abortion clinic, for example, offers abortions up to only 16 weeks, even though the state allows abortion until 20 weeks (at least for now). This is an issue even in liberal states. According to our analysis of clinic websites, a sizable chunk of California’s clinics offer only medication abortion, which means they can’t serve women who are past 10 weeks of pregnancy. And other California clinics perform surgical abortions only through the end of the first trimester.


100 abortion clinics or just one

The pink lines on a positive pregnancy test look the same whether it’s sitting on a bathroom counter in Jackson, Mississippi, or Los Angeles. But for the woman who took that test, where she lives will determine whether she has lots of options for where to get an abortion, or just a few.

The vast majority of abortions happen in freestanding clinics scattered across the country. But those clinics aren’t spread out evenly — a national map looks like someone lobbed a handful of dots at each of the coasts, sprinkled a few more in the middle of the country, then called it a day.

According to a dataset of abortion providers compiled by Caitlin Myers, an economics professor at Middlebury College who studies reproductive policy, about one-third of the country’s abortion providers are in New York and California alone. Other states have fewer abortion clinics, particularly in the Midwest and South, which means that travel times are often much longer. It also means that clinics outside of cities are often serving a much larger population, which can mean longer wait times for appointments. On the West Coast, where abortion clinics are relatively plentiful, that means travel distances can be long for women who live in rural areas. And in the heart of the country, abortion clinics are even more scarce, leading to longer travel times and longer waits.

Swipe to see more of the map →

Travel time is measured by the driving time between the population centroid of each county and the geographic coordinates of the nearest abortion provider, calculated under normal traffic conditions. Congestion is measured by the “average service population,” which is the average number of women of childbearing age per abortion facility in a set of counties that share a common nearest destination county or commuting zone to obtain an abortion. Abortion provider data as of June 2021.
Source: Caitlin Myers

I Googled around, searched for Planned Parenthood and abortion clinics. There was an abortion clinic in Wichita, but I don’t think they had any appointments available, so Planned Parenthood was the best option. It was about four and a half, five hours from me. … I missed class, left early in the morning to drive halfway across the entire state. A whole day out of my life just to get an abortion.

–Kaila, Kansas

Still, in states with dozens of providers, figuring out where to get an abortion can be hard. Searching around online, it can be difficult to tell whether you’ve landed on a clinic that actually offers abortions or a crisis pregnancy center that tries to convince women to choose another path. Even trusted doctors may not be much help. Chances are, a woman’s own OB-GYN won’t offer an abortion. At Catholic hospitals, which make up a significant share of American health care providers, doctors are prohibited from providing abortions. Some Catholic hospitals also bar their doctors from referring women seeking abortions to clinics that perform the procedure.

Getting through to a clinic — and making an appointment — can also be a challenge. That’s another factor that varies widely from region to region. Following Texas’s six-week abortion ban, clinics in states adjacent to Texas have seen wait times skyrocket, commonly exceeding two weeks. But simply residing in a state with few or no abortion restrictions doesn’t mean a woman can get an appointment right away. Some women who had abortions in bluer states, like California, told us they had to wait a week or more for an appointment. And when we checked appointment availability at 58 abortion providers across California, we found that wait times were all over the place. Some waits were as little as a day in big cities like Los Angeles or San Francisco, but others were up to two weeks in less urban areas, especially rural northern and central California. That might not sound like a noteworthy delay, but when you’re pregnant and don’t want to be, an extra week can feel like a lifetime.

When I finally found an abortion clinic near me, I had to keep calling… I kept pushing repeat over and over again. And even then, my appointment was 10 days out… That’s when it clicked for me — that even though I live in California, where abortion’s legal, there’s a difference between legality and permissibility. Whether you’re theoretically allowed to get it and whether you actually can.

–Emily, California


Asking a judge’s permission

Most women who get abortions get to choose who they tell about the procedure, even if that means telling no one at all. But that’s not the case for girls under the age of 18. Most states require some level of parental involvement in a minor’s decision to get an abortion. That could mean notifying at least one parent, requiring one parent to give consent, requiring both parents to give consent, or requiring parental notification and consent.

Data as of Feb. 1, 2022.
Source: Guttmacher Institute

Some states have limited exceptions, allowing minors to bypass these rules if it’s a medical emergency or the pregnancy is the result of rape or incest. But for the most part, minors who want to avoid involving their parents have to get a judge’s permission to get an abortion instead. And getting a judge to sign off, a process known as “judicial bypass,” can sometimes take weeks. Research has found that even in restrictive states like Texas, most judicial bypass requests are eventually approved — but not always.

For my meeting with the judge, I had to memorize every single step of the procedure. … It meant memorizing all the tools that were needed and what was going into my body and how my abortion worked. I had to acknowledge that abortion could cause death, … that the person who got me pregnant would pay child support and that adoption is an option. It was like cramming for a test, the scariest possible test. Talking about it still makes me shake four years later.

–Anna, Texas


Anywhere from $500 to more than $1,000

Most women who get abortions are lower-income. Figuring out how to pay for the procedure is often the biggest challenge they face, too, as federal funds can’t be used for abortion except in limited circumstances, which has made it challenging to cover abortion under Medicaid. Some states use their own Medicaid funds to cover abortion, but most don’t.

Other states have made it practically impossible to avoid paying out of pocket for an abortion. They restrict abortion coverage either in health insurance plans sold through the Affordable Care Act marketplace, in insurance plans for public employees or in private insurance plans written in the state. In a handful of states, such as California and Illinois, private insurance is required to cover abortion — but patients with high-deductible plans sometimes end up paying out-of-pocket anyway.

Of the states that restrict abortion coverage in health insurance plans, many limit coverage to pregnancies that endanger the life of the woman, resulted from rape or incest or have a fetal abnormality. Data as of Feb. 1, 2022.
Source: Guttmacher Institute

[A clinic employee] literally came and told me that my insurance didn’t go through while I was talking to the doctor. … They said, “Don’t give her the medication. We don’t take that insurance.” So I had to make a phone call on the spot to come up with the $700 for the pills. At that point, it was about two weeks since I had found out I was pregnant, and I did not want to delay this any more. … Luckily, I was able to make the call. It was embarrassing and really demoralizing.

–Larada, California

The out-of-pocket cost of an abortion can vary a lot. A California agency recently reviewed abortion costs and found that patients in the state paid an average of $306 for a medication abortion and $887 for a surgical abortion. And in 2014, a study conducted at 30 clinics across the country found that when insurance or Medicaid didn’t pay for an abortion, the median cost was $575. That varied a lot, though, depending on the stage of pregnancy at which the woman was trying to get an abortion. A first-trimester abortion, for instance, could cost less than $500, but a second-trimester abortion could cost almost twice as much.

And to someone already struggling to make ends meet, even the less expensive procedures aren’t cheap. In the study, more than half of the women who paid out-of-pocket were handing over more than one-third of their monthly income when factoring in the cost of travel and the procedure. Some women delay bills or avoid buying groceries to cover the cost.

We had a remaining balance of almost $500, which was really stressful because I didn’t have the money and I couldn’t ask my mom. It was like, Oh shit, we went through this whole process and maybe we can’t even pay for it. So my partner’s mom talked to his dad and told him what was going on, and he paid the rest. It saved us. And I felt so guilty because I knew that was almost one-third of their rent.

–Veronika, Texas

Many women turn to family members or abortion funds to pay for the procedure and cover related costs, like travel. But the process of cobbling the funds together takes time, and there’s a catch-22 for lower-income women: The longer it takes to get the money together, the more expensive the procedure will be. A 2014 study in the American Journal of Public Health found that two-thirds of women who were near the gestational limit of the clinic where they ultimately received an abortion said that travel and procedure costs delayed getting their abortion, compared with 37 percent of women who had an abortion in the first trimester.

Source: American Journal of Public Health

Asking family members for help isn’t always an easy option, either. Many women told us they didn’t want to talk to people who were close to them about their abortion, fearing they’d be judged or criticized. For some, that meant making a vulnerable request of people they didn’t know well.

Insurance did not cover a thing. [The abortion] was between $700 and $800. That’s a lot of money when you’re low-income. We had to pay it all out of pocket, and if it wasn’t for the grandma of the guy who got me pregnant, I might have a kid right now, honestly. She paid for half of it.

–Heather, Ohio


Protesters and restrictions at the clinic

In some states, arriving at the abortion clinic is just the beginning of a several-day ordeal — starting with navigating the protesters who gather outside abortion providers, hoping to convince women not to go through with the procedure. Several women told us that simply walking into the clinic was a more jarring experience than they’d been expecting.

There was a young girl outside of the clinic, and she was holding rosary beads and just looking at the people who were going in and out. I remember looking at her and thinking, You have no idea, you just don’t understand my situation. Before I got pregnant, I had always been pro-choice … but I didn’t think I would have an abortion. It made me realize that in this situation you don’t know what you would do. But there are so many people hating you for your decision.

–MJ, Texas

Once inside the clinic, though, restrictions can start to envelop the patient — adding time, expense and sometimes confusion. According to an analysis from the Guttmacher Institute, a majority of states (33) require some form of pre-abortion counseling, which often includes scary and medically inaccurate information, such as telling women that abortion is linked to breast cancer or infertility. (Neither of which is true.) Half of states (26) impose a waiting period between when a woman receives the counseling and when she can have an abortion. And in 13 states, the counseling has to be conducted in-person before the waiting period begins, which means the woman must make at least two trips to the clinic. In most states with a waiting period, the waiting period is 24 hours, but two states have a 48-hour waiting period and six states require women to wait 72 hours.

These mandatory waiting periods may require a woman to make two trips to the health care provider if the state requires the woman to receive in-person counseling and then wait a set amount of time until the abortion appointment. Data as of Feb. 1, 2022.
Source: Guttmacher Institute

The visits add up. A study conducted in 2019 in Mississippi, which has a 24-hour waiting period, found that almost half (43 percent) of patients traveled more than 50 miles one way to get to the clinic, and 57 percent had to miss work. Some women we spoke with had to return to the clinic three or four times — not just for the counseling and the abortion procedure itself, but also for follow-up visits and ultrasounds.

In 17 states, an ultrasound is required, even though that’s not considered medically necessary for a first-trimester abortion. Often, the ultrasounds are pretty uncomfortable, too; several of the women we spoke with had a vaginal ultrasound, rather than the abdominal ultrasound they were expecting. In six states, the provider has to display and describe the ultrasound image. And in eight states, the provider has to offer the woman an opportunity to view the image.

In New Hampshire, North Carolina and Oklahoma, the abortion provider is not required to offer the woman an opportunity to see the ultrasound image. Data as of Feb. 1, 2022.
Source: Guttmacher Institute

They brought me to a room, and I got a sonogram. It was vaginal, which was more invasive than I was expecting. At some point, they were like, “The state requires us to show the screen to you, but you don’t have to look. … We have to tell you the size — it’s the size of a blueberry.” … Every little burden, every little inconvenience — it felt intentional. Like someone had known what they were doing … and they wanted me to feel shame.

–Cali, Wisconsin

For many women, the time it takes to navigate state-imposed restrictions isn’t just an annoyance. It means more days off work, more hours of lost pay, more childcare gaps to fill, more gas to buy. In some states where doctors are required to give abortion pills in person, it can take three visits to get a medication abortion — one for mandatory in-person counseling, another to take the pill, a third to make sure that the pregnancy is gone.


All of these barriers are psychologically and physically taxing. Women told us they felt like they were being punished. They felt like they must have done something wrong. They felt alone.

With the repeated visits, having to wait more than a week from when I knew to when I could actually make the appointment, … it honestly felt personally hurtful because all of these steps are due to people’s opinion of what you’re doing. … It’s not that I think I should be ashamed of this, but that’s the constant communication throughout the process. The reason I’m supposed to have the ultrasound and get counseling is because everyone thinks this should weigh on you so heavily that you’ll realize what you’re doing is wrong. … I have to act like it’s something shameful, and I don’t feel like it’s something shameful. That’s where the guilt starts.

–Stella, Mississippi

In states like California, where access to abortion has relatively few legal restrictions, some women were still surprised by how difficult it was to get an appointment and pay for the procedure. In our review of appointment availability at 58 clinics in California, we found that at 21 percent of abortion providers, the soonest available slot was a week or more away. Twelve percent of the providers said their soonest available appointment was 10 days or more in the future. And while abortion is covered by Medicaid in the state, which means the procedure could cost nothing for some women, high deductibles can leave women with private insurance footing the entire bill. Several of the women we spoke with told us that they realized for the first time that the South isn’t the only place where it can be hard to get an abortion.

In California, it’s supposed to be easy to get an abortion. But for me, it wasn’t easy. Even though … I was doing everything I could to get it done, it felt like the world was telling me no.

–Jessy, California

The Supreme Court may soon dismantle constitutional protections for abortion. But in practice, this right has already been hollowed out in much of the country. States with more restrictions have spent decades trying to make it as difficult as possible to get an abortion, and they’ve been successful. Even outside of those states, though, having an abortion is often complicated, expensive and hard to talk about — a secret that some women hold onto for years, never telling more than a few people. To those women, abortion didn’t really feel like a right — unless a right is something you have to struggle at every step to exercise.

Some names have been changed to protect people’s identities.

Additional research by Jean Yi. Art direction by Emily Scherer. Copy editing by Andrew Mangan and Curtis Yee. Story editing by Sarah Frostenson. Visual editing by Christopher Groskopf.