Although abortion is technically legal in the U.S., access varies widely. State laws dictate which specific procedures are allowed, which health care providers can perform them and even who can get an abortion. Access is also shaped by how many facilities there are in a given area that are capable of providing this kind of medical care. These conditions vary widely, and the restrictions they impose fall most heavily on poor women, rural residents and minors.
North Carolina abortion law doesn’t specify a particular week after which the procedure is prohibited; instead, it focuses on fetal viability, notes Elizabeth Nash, principal policy associate for state issues at the Guttmacher Institute. The national nonprofit conducts research and advocates for policies promoting sexual and reproductive health and rights worldwide.
In North Carolina, “Viability has to be determined by a physician,” she explains, adding that it’s typically said to be achieved 24-26 weeks into a pregnancy. Terminating a pregnancy after that time is legal only if the patient’s life or health is at stake. Life endangerment is determined by on a case-by-case basis by a physician, says Nash.
Planned Parenthood’s Asheville Health Center is Western North Carolina’s lone abortion provider. It can terminate pregnancies at up to 14 weeks, the facility’s manager reports. (Xpress is granting this person anonymity due to legitimate security concerns.) The clinic offers both surgical and medication abortions one day per week — less frequently than in the past, the manager reveals.
The closest Planned Parenthood clinic that provides abortions after 14 weeks is in Chapel Hill, the Asheville center manager explains. “Mid-trimester abortions are typically done with moderate sedation, and at this time, we are not offering that here.”
A facility’s ability to offer these procedures depends on having accredited providers, she says. In North Carolina, only physicians can perform surgical abortions. In 18 other states advanced practice clinicians, such as physician assistants or certified nurse midwives, are allowed to terminate pregnancies, notes Nash.
No local access in most N.C. counties
A 2017 study by the Guttmacher Institute found that 53% of women in North Carolina live in counties with no abortion providers. Ninety-one of the state’s 100 counties don’t have an abortion provider, says Jillian Riley, North Carolina director of public affairs for Planned Parenthood South Atlantic, which operates the Asheville clinic.
According to the study, 26 facilities across the state provide abortions. Of these, 14 are clinics, some of them independent and others operated by Planned Parenthood. Most of the remaining providers are hospitals, which typically end pregnancies only in emergencies, says Nash.
“North Carolina is a state where access is really available in cities,” she points out. “When you get beyond cities, then access is very hard to come by. People have to drive very long distances.”
Having to travel makes ending a pregnancy less feasible for many women, increasing the cost and further complicating the already limited window for getting the procedure performed.
“Abortion is time-sensitive,” says the Planned Parenthood manager. “What a lot of times gets missed is that scheduling these appointments can be stressful for that reason. Not everyone has the availability in their schedule that aligns with the availability at their local clinic.”
When it’s allowed, where it’s available and who pays
The cost of terminating a pregnancy varies by the type of procedure performed. Nationwide, however, the mean cost of an abortion at 10 weeks is $550, says Nash.
And in any case, only limited help is available for individuals who can’t afford to pay.
North Carolina’s Medicaid program covers abortion only in cases of rape, incest or life endangerment. The same holds true for plans offered on the state’s health exchange under the Affordable Care Act, and for the policies provided for public employees. Private insurance plans are not required to offer abortion coverage.
As a result, policyholders may have to ask their insurer whether the procedure is covered, Nash explains, adding that “a lot of people pay out of pocket” for an abortion to protect their privacy.
Planned Parenthood’s Asheville clinic accepts both Medicaid and private insurance plans for its services, including abortions. But Western North Carolina Community Health Services, a federally qualified community health center in Asheville that serves patients covered by Medicaid, doesn’t terminate pregnancies, CEO Kim Wagenaar told Xpress. Neither does Appalachian Mountain Community Health Centers, another federally qualified organization with locations in Asheville, Leicester, Sylva, Murphy and Robbinsville.
Other major local health care providers likewise choose not to perform abortions. That’s the case with OB/GYNs employed by the Mountain Area Health Education Center, says spokesperson Jennifer Maurer. Those providers actually work out of Mission Hospital, which also doesn’t terminate pregnancies, Mission spokesperson Nancy Lindell confirms.
MAHEC’s OB/GYN residency program does include training in pregnancy termination. All residents do a rotation at Planned Parenthood and are taught the dilation and curettage procedure, which removes tissue from inside the uterus. A D&C can “address causes of heavy uterine bleeding, after a miscarriage or in pregnancy termination,” says Dr. William Gist, the residency’s program director. The residents, he emphasizes, aren’t required to assist with abortions during the training.
And Dr. Greg McCarty, chief medical officer at Pardee UNC Health Care, says the Hendersonville-based facility “does not have any physicians or providers who perform elective surgical or medical abortions.”
The same is true at the Charles George Department of Veterans Affairs Medical Center in Asheville, says public affairs officer Vance Janes. Federal regulations exclude both abortion and the discussion of pregnancy termination as an option for both veterans and VA employees, he says.
Representatives of Swain Community Hospital in Bryson City, Harris Regional Hospital in Sylva and AdventHealth Hendersonville did not respond to requests for comment.
North Carolina’s abortion laws create “far more hurdles than there need to be,” the Planned Parenthood health center manager maintains.
Under state law, patients seeking an abortion must receive counseling by a registered nurse, nurse practitioner or physician assistant and then wait at least 72 hours before undergoing the procedure. At Asheville’s Planned Parenthood clinic, nurses provide the required counseling over the phone. Certain topics must be covered, including the health risks associated with both abortion and pregnancy, says Nash.
According to the Planned Parenthood health center manager, the counseling is “definitely designed to discourage abortion,” adding that this amounts to another hurdle for patients.
During abortion appointments, patients are required to have an ultrasound, and clinics must offer them materials developed by the N.C. Department of Health and Human Services containing a list of medical centers that have specialists on staff to serve patients with high-risk pregnancies, Nash explains. The law does not require patients to read the materials, however.
North Carolina regulations require both a physician and a registered nurse with training in postoperative care to be on-site whenever any patients are present in the facility, regardless of what kind of care they’re receiving. According to Nash, the training in postoperative care is “an unusual requirement” for nurses, compared with the rules in other states. And Riley of Planned Parenthood South Atlantic says this mandate burdens clinics by requiring them to have certain staff on-site “even when it is not medically necessary for them to be in the building.”
Meanwhile, minors seeking to end a pregnancy face an additional hurdle: consent from a parent or guardian. And while there is another option in such cases, it too may be problematic.
“If the person who is pregnant and under age 18 does not want to get parental consent, or they would be put in harm’s way if they contacted their parents, they have to get permission from a judge to receive an abortion,” Riley explains.
She adds that minors pregnant as the result of either incest or rape — two of the situations in which the law allows abortions — may be reluctant to discuss their pregnancy with a parent.
Medication abortion begins with a single mifepristone tablet. According to the Mayo Clinic’s website, this drug blocks the body’s production of progesterone and prevents the pregnancy from continuing. Two days later, patients receive four misoprostol tablets, which cause cramping and empty the uterus. These are taken all at once.
The pills can be prescribed at up to 10 weeks of pregnancy in most states, according to Guttmacher. In 32 states, including North Carolina, only physicians can prescribe medication abortions — and, in N.C. and 18 other states, the physician must be physically present when the first dose is administered. In North Carolina’s case, says Nash, it’s unclear whether “administered” means receiving the first pill from a physician or consuming it in the physician’s presence.
But ideally, she explains, patients should take the abortion pills at home rather than in a physician’s office, because “the abortion could start while you’re driving home, and that would not be what you want.”
North Carolina is also one of 19 states that prohibit the use of telemedicine in prescribing medical abortions, according to the Guttmacher fact sheet.
“Telehealth and using it for medication abortion is something that people need, because of all the difficulties in getting to a clinic and arranging their work life and childcare,” says Nash.
Riley, meanwhile, says that North Carolina’s regulation of medication abortion creates “so many more steps, and so many more barriers for folks who don’t have access to an abortion provider in their county.”
Far from deterring local providers, however, these restrictions “just make us want to commit ourselves to this work day in and day out, because these folks need us,” says the Asheville Planned Parenthood clinic manager. “Care is important — and we’re here to provide it.”