Hillary Brandenburg, 33, at the historical Lower Harbor Ore Dock in Marquette, MI on Dec. 10, 2021 | Allison R. Donahue
When Hillary Brandenburg found out she was pregnant nine years ago, she was 24 and had no desire to be a mother. She was confident in her choice to get an abortion.
What she wasn’t sure about was how she would get to the reproductive health clinic about 250 miles away.
It is a question faced by many pregnant people who live in rural areas, like Brandenburg, when considering their options for abortion. That’s because these rural areas are often “abortion deserts,” requiring travel of more than 100 miles to access providers.
“There were a lot of barriers coming from a rural area,” Brandenburg recalled.
At the time, she lived in Chatham, a small village of just over 200 people in the Upper Peninsula, near the popular travel destination of the Pictured Rocks National Seashore. She was paying her way through college at Northern Michigan University (NMU), living with her husband whom she had married just four years earlier and driving a 1996 Subaru Legacy that wasn’t sure would make it to the Planned Parenthood in Traverse City.
The Planned Parenthood clinic in Marquette, the largest city in the U.P., wasn’t able to perform abortions at that time. So Brandenburg knew she had two options: Head to the clinic in Green Bay, Wisc., (a three-hour drive) or Traverse City (a four-and-a-half-hour drive).
She didn’t want to cross state lines into Wisconsin because the state requires in-person counseling and a 24-hour waiting period. That would mean two trips to the clinic. So she and her husband rented a car and made the nine-hour round trip to Traverse City.
“I recognize my privilege here, even though there are a lot of barriers for rural women. I had money to rent a car, I had money to pay for the abortion and I had a supportive partner who didn’t stand in my way,” Brandenburg, 33, told the Advance last month.
Even before the landmark Roe v. Wade decision guaranteeing the constitutional right to abortion was placed in the crosshairs of a right-wing-majority U.S. Supreme Court, abortion access around the nation was already limited for millions of people. As lawmakers across the country have imposed additional restrictions in recent years, the number of providers has dwindled.
Abortion deserts exist in every region of the U.S., except for the Northeast. Kentucky, Mississippi, Missouri, North Dakota, South Dakota and West Virginia have only one abortion facility to serve their entire states. Most abortions in Texas are illegal after enacting Senate Bill 8, the most restrictive such law in the U.S. to go into effect, which bans abortions as early as six weeks with no exceptions for incest or rape.
“If we’re thinking about abortion deserts, there are a lot of barriers that exist for people trying to access care, and it’s everything from finding an abortion provider to being able to navigate all the logistics in getting to the provider and home again and those logistics can include an additional hundreds of dollars,” said Elizabeth Nash, state policy analyst for the Guttmacher Institute, a Washington, D.C.-based abortion rights think tank.
Who is most affected by abortion deserts?
Last year, states enacted more than 100 laws putting additional restrictions on abortion, the most ever. Michigan’s GOP-controlled Legislature introduced several bills that could have created additional challenges for the state’s nearly two dozen clinics.
But the new regulations didn’t make it to Michigan Gov. Gretchen Whitmer, a Democrat, who has said she’ll veto anti-abortion bills.
“The only thing right now that’s keeping Michigan from looking like Texas, whether it’s on voting rights or women’s autonomy and health rights, is my veto, and that tells you how precarious this moment really is,’’ Whitmer told the Advance in a recent interview.
In 2012, Whitmer’s predecessor, GOP former Gov. Rick Snyder, signed an omnibus abortion restriction law that, among other provisions, requires providers that perform at least 120 abortions per year to meet the same architectural and licensing requirements as ambulatory surgical facilities. The legislation was intended to close clinics that couldn’t meet those demands from the state.
In 2017, about 87% of Michigan’s 83 counties had no clinics that provided abortions, and 35% of the state’s women lived in those counties, according to the Guttmacher Institute. That’s slightly better than the national outlook, which sits at around 89%.
Today, the Marquette clinic offers medication abortion services, expanding access to many women in northern Michigan, although it is only open three days a week. Doctors at the Marquette clinic estimated that there are about 20 appointments each day for a variety of services, including abortion care, STI testing, birth control or annual exams.
Other options for those living in the vast areas of the U.P. and the northern Lower Peninsula are the Women’s Center of Saginaw, Planned Parenthood of Traverse City and Planned Parenthood of Petoskey.
That means extensive travel and other expenses for people living in norther rural communities, where nearly half of the population lives under the poverty line. In addition, Michigan also has a 24-hour waiting period, which could require additional travel and expense.
Abortions average about $550, Nash said. But that’s often just the beginning. Many patients need to take time off from work and arrange for childcare, since 60% have children, according to the Guttmacher Institute.
These added expenses hit hard for many people seeking abortions, as nearly half of abortion patients nationwide, 49%, live below the poverty line, according to Guttmacher. A family of four meets the poverty threshold with an income of $29,820.
The poverty rate in rural Michigan is 13.3%, compared with 12.9% in urban areas, the USDA Economic Research Service reports based on 2019 American Community Survey (ACS) data. The poverty rate for the U.P., based on 2014–18 five-year estimates from the U.S. Census Bureau, was at 15.6%, according to the Michigan Department of Technology, Management and Budget (DTMB).
It's nerve-wracking when you have patients traveling that far for a service and they’re like, ‘I have to. I don’t have another option. I have to do this today.'
– Anna Rink, physician assistant at Planned Parenthood in Marquette
Still, many of those in need found their way to services.
In 2020, 28,048 Michiganders from every county across the state got an abortion. That number was up about 2,500 compared to 2019.
In northern Michigan and the Upper Peninsula, there were 556 pregnant people living in the northern Lower Peninsula and 215 pregnant people from the U.P. who got an abortion in 2020, according to Michigan Department of Community Health data.
The state doesn’t have data on where they obtained services, but many would have had to travel more than 100 miles. For example, the 29 pregnant people in Chippewa County who obtained abortions in 2020 had two options without crossing the border into Canada: the Marquette Planned Parenthood (about 165 miles from Sault Ste. Marie) or the Traverse City Planned Parenthood (about 175 miles from the city).
According to Planned Parenthood, 67% of the people obtaining abortions at the Marquette clinic from September 2020 to August 2021 traveled from another county and 6% traveled from out of state, primarily from northern areas of Wisconsin and Minnesota.
“We had a storm earlier this week and had a patient coming from Northern Wisconsin and drove through all that snow,” Anna Rink, a physician assistant at Planned Parenthood in Marquette, told the Advance in December. “We called her and told her she could come tomorrow, but she was determined. The whole time I was worried about her. Luckily, she made it here safely. But it’s nerve-wracking when you have patients traveling that far for a service and they’re like, ‘I have to. I don’t have another option. I have to do this today.’”
Many states ban abortion at some point in a pregnancy, which compounds issues for those living in abortion deserts. Texas has the most restrictive time limit at six weeks, but 22 other states ban abortion between 13 and 24 weeks, according to the Guttmacher Institue. The majority of states with these restrictions ban abortion at viability, including Michigan.
Statewide, 1,621 pregnant people traveled from out of state to get an abortion in Michigan in 2020.
At times, the best option for patients might not be the closest.
“Women do travel from the Upper Peninsula downstate,” said Dr. Laura Sabo, an obstetrician-gynecologist at Planned Parenthood in Marquette. “It might be an access issue sometimes. There might not be appointments available in Marquette because it’s the only office in the Upper Peninsula.”
And for women who need surgical abortions, the choices are even more limited.
“The U.P. certainly meets the criteria for a desert regarding [surgical] procedures, and for some locations, medical, too,” said Sabo. “If a woman needs a surgical procedure, that’s not available in the Upper Peninsula. And it’s not available even if there’s a fetal anomaly or threat to the mother’s health. They have to leave the Upper Peninsula for that service.”
Restrictions on abortion increase
Anti-abortion legislation in Michigan in the last decade increased the number of regulations reproductive health care providers have to meet in order to offer abortion services.
These restrictions make it impossible for some clinics to keep their doors open and deter other medical providers from offering the procedure.
A decade ago, Snyder signed into law House Bill 5711, which at the time was considered one of the nation’s most restrictive anti-abortion bills. The omnibus law increased reporting requirements for clinics to the Department of Licensing and Regulatory Affairs (LARA) and required doctors to purchase liability insurance if they perform more than four abortions a month. The law also requires any clinic providing at least six abortions a month to be licensed as a “freestanding surgical outpatient facility” — so even if a clinic does not offer surgical abortions, it would be required to have a full surgical suite.
These new regulations have been financially burdensome for clinics, many of which are largely funded by donations.
- An abortion may only be performed after viability if the patient’s life is endangered.
- Mandatory counseling at least 24 hours prior to the procedure.
- Individuals must purchase additional coverage if they want their private insurance or health plans under the Affordable Care Act to cover the cost of abortion, since the state only allows for insurance policies to cover abortion in cases of life endangerment.
- Parental consent for minors is required.
- Public funding is available for abortion only in cases of life endangerment, rape or incest.
- Reproductive health clinics providing abortions must meet physical structural standards comparable to surgical centers. The facility must must be within 30 minutes of a hospital and have a transfer agreement with that hospital.
From 2011 to 2016, Michigan lost 13 clinics, according to a report from Bloomberg Business.
Since 2012, Michigan’s GOP-led Legislature has continued to roll out more regulations, including increased targeted regulation of abortion provider (TRAP) laws, such as rules mandating the facilities physical composition and being located within 30 minutes of a hospital, with no exceptions for rural areas.
Michigan also has a 24-hour consent law, which requires that certain information be made available to a pregnant person at least 24 hours prior to the abortion procedure.
“That’s where the consent barrier comes in,” said Sabo, who estimates that at least once a day someone comes in who missed the consent period. “They have to have that printed out 24 hours before coming into the clinic.”
In many cases, there isn’t anything stopping other medical offices from offering abortions, but barriers in place make it too great of a burden, Sabo said. She said it’s likely that more offices would do pill abortions and more private OB-GYN offices would do surgical procedures if it weren’t for the “political pushback.”
“I think for a lot of hospitals, it is so much easier to just say, ‘No, we’re not doing this service’ than to justify why you are. You catch a lot less flack by just not doing it,” Rink added.
Is telemedicine the solution for abortion deserts?
Because of extensive regulations on clinics, some believe the internet is the answer to increase access to abortions for rural areas.
Michigan currently allows for telemedicine abortions, where patients get online access to abortion medication using mifespristone and misoprostol taken during the first 10 weeks of gestation. Health care providers then prescribe or supervise the use of the pills through video or telephone meetings.
However, patients must have an ultrasound before the abortion, which still requires patients to go into a clinic.
“Telemedicine abortion option has definitely increased access and improved access, including in Marquette,” said Sabo, who does telemedicine abortions across the state.
Planned Parenthood patients go to a clinic for an intake appointment and ultrasound and the provider is remote. Then if the patient is eligible for abortion medication, the patient receives the pills in the clinic.
A positive that came out of the pandemic was telehealth and making that process more streamlined.
– Dr. Laura Sabo of Planned Parenthood in Marquette
“A positive that came out of the pandemic was telehealth and making that process more streamlined, for lack of a better word,” said Sabo. “But people still have to travel to an office, so having more offices across the state would help with that part of it.”
Reproductive rights advocates are on alert as they await the U.S. Supreme Court decision in a Mississippi case, Dobbs v. Jackson Women’s Health Organization, which aims to ban abortions after 15 weeks — and could overturn the landmark Roe v. Wade decision. If Roe is overturned, Michigan would revert to a 1931 state law criminalizing abortions, thus making the entire state an abortion desert.
So groups in Michigan are working to enshrine the right to abortion and reproductive health care in the state’s Constitution. Earlier this month, the Board of State Canvassers approved language for a 2022 ballot petition affirming Michiganders’ right to make and carry out decisions relating to pregnancy, abortion, birth control, prenatal care and childbirth.
“This is fundamental health care and people making decisions about their lives and futures,” said Nash. “And we need to make it available to people so that they can create the future that they need for themselves and their families.”
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