When she discovered she was pregnant, the 22-year-old aspiring veterinarian started calling abortion clinics in her home state of Oklahoma. It was a short list – there are only two, and neither could get her an appointment quickly.
Unemployed, no car, and still living with her parents, Pearl thought about trying Texas, but knew the state had also recently tightened restrictions on clinics.
Finally, Pearl – who asked not to use her full name for fear of upsetting her conservative family back in Comanche County – got her boyfriend to take her to South Wind Women's Center in Kansas, a four-hour drive north.
"It's ridiculous that I have to travel," Pearl said as she waited at the clinic last week to get abortion medication. "Not everyone is as strong as this. Not everyone is made of stone. It's stressful to travel all this way."
The National Abortion Federation hotline referred 209 Texas patients to New Mexico last year, compared with 21 in 2013, said Vicki Saporta, the group's president and chief executive. The number of Texas patients at one Albuquerque clinic alone more than tripled, jumping from 19 to 67 last year, she said.
As more states adopt more restrictive laws and the number of clinics dwindles in the so-called "abortion desert" – an area that stretches from Florida to New Mexico and north into the Midwest – women are increasingly traveling across state lines to avoid long waits for appointments and escape the legal barriers in their home states.
As states have embraced laws requiring waiting periods for abortion, admitting privileges for abortion doctors and medical upgrades for clinics, the number of facilities where a woman can get an abortion has declined rapidly and wait times for appointments have grown longer. Longer waits can mean the difference between women taking abortion medication, generally available up to 10 weeks, and progressively more expensive surgical abortions.
In Texas, the number of clinics has fallen from 41 to 19 in the last three years. In Louisiana there are four; in Arkansas three. Missouri and Mississippi have one clinic each. About 49% of women in the South live in counties without an abortion clinic, as do 53% of women in the Midwest, compared with 38% nationwide, according to the most recent study by the Guttmacher Institute, which advocates for reproductive rights.
"When we see women having to travel long distance, across state lines or hours away from their home to get the care they need, it has a rippling impact," said Whitney Phillips, a spokeswoman for Planned Parenthood of the Rocky Mountains, whose clinics have also recorded an increase in out-of-state clients. "They are having to arrange their work schedules, child care, travel and finances in order to see a provider. In the event they need more than one appointment, that can be crippling – especially for lower-income women."
In Texas, abortion provider Whole Woman's Health has sued to block a new law that would force about half the state's remaining clinics to close, alleging it amounts to an "undue burden" for women forced to travel long distances. The U.S. Supreme Court is expected to rule on the case this month, its first major ruling on abortion in two decades.
If the high court sides with Texas, or sends the case back to the conservative U.S. 5th Circuit Court of Appeals, similar laws stayed by the courts could be enforced in Kansas, Michigan and Wisconsin, closing clinics there too.
Since the Texas law passed, women have had to drive four times farther for abortion services – from 17 to 70 miles – and often wait three times longer for appointments, according to studies by the Texas Policy Evaluation Project. About 10% of the women surveyed report having to drive at least 250 miles to reach a clinic.
Because of the new laws, a clinic in Dallas started encouraging West Texas women to make appointments at its facility in Albuquerque, which had shorter waits and restrictions – but was still about 300 miles away. Since the law passed, the number of women traveling to New Mexico for abortions has more than doubled. In Kansas, the number of women arriving from Oklahoma and Texas soared from 38 to 243. The trend is similar at clinics in Louisiana.
New Mexico clinics can treat more patients because the state has not passed many of the laws Texas has, including a 20-week abortion ban passed by a dozen other states.
"The need has really exploded," said Joan Lamunyon Sanford, executive director of the New Mexico Religious Coalition for Reproductive Choice.
She says many women cannot afford to fly, so they take buses instead, some traveling for days from California and the East Coast.
"Nobody should have to go across two or three states to get healthcare," said Sanford, whose volunteers provide women with transportation, childcare and housing during clinic visits.
Doctors are also on the move to handle the shifting waves of patients, flying to New Mexico and Kansas to help staff clinics.
Dr. Colleen McNicholas flies from St. Louis to work at the Wichita clinic, where 40% to 50% of her patients are from out of state, usually Oklahoma and Texas, occasionally Missouri.
McNicholas says she has seen women sleeping in their cars in the parking lot.
"Either they don't want to wait or can't because of how far along they are," she said. "So they look at a map and map it out, keep trying, keep calling clinics until they find one that can take them."
Dr. Willie Parker recently relocated from Illinois to Alabama to perform abortions there and in Georgia and Mississippi. Many providers in the region won't handle abortions beyond 15 weeks, he said, creating "watershed areas" where women must seek care across state lines.
"If they don't make the cutoff, they're coming over to Tuscaloosa," Parker said. "People are coming from everywhere."
He says he has placed dilating devices in out-of-state patients for a two-day procedure only to see them drive hundreds of miles home to avoid paying for a hotel.
Some out-of-state patients are no-shows, unable to handle travel costs, he said: "You have a lot of women who are staying pregnant because they can't surpass that barrier."
Antiabortion activists say they are encouraged to see clinics close due to laws that they say protect women's safety.
"I do think that's a good thing. I think there should be regulations. It should be safe, like going to a hospital," said Courtney Love, 30, a self-described "sidewalk counselor" distributing antiabortion leaflets outside the Wichita clinic. The fenced-off clinic has been a battleground in the abortion debate, drawing large crowds of protesters and closing for several years after its director, Dr. George Tiller, was fatally shot by an antiabortion extremist.
Love and other antiabortion volunteers say they have noticed more cars with out-of-state license plates arriving at the clinic. She says she doesn't like the idea of women being forced to travel to get services, but "there's other choices for them other than abortion."
She pointed to a neighboring antiabortion counseling center.
"Next door there's help, people who will help with their rent and adoption," Love said.
Brittany, 22, of Oklahoma City, already gave up a son to adoption last year, and says she didn't want to do that again. A heroin addict, she came to the Wichita clinic in maternity jeans for a surgical abortion at 17 weeks. She would not have been able to get there without her father, an Air Force officer in Tampa, Fla., who rented a car, booked a hotel and paid $1,300 for the procedure.
"I was scared I would be too far along," she said. "Now I'm scared I may have to stay overnight again and my dad may have to miss work."
As Pearl prepared to return to Oklahoma, she said she realized her situation wasn't unique.
"I have two friends who are pregnant wondering if they can get abortions because of the laws," she said.