By Rachel Crumpler
Patients, health care providers and clinics were thrust into a new era of reproductive health care access on July 1 when the state’s increased abortion restrictions took effect.
The new North Carolina law limits most abortions after 12 weeks of pregnancy and requires two in-person appointments for anyone seeking an abortion. Lawmakers added an in-person requirement to receive state-mandated counseling at least 72 hours before an abortion — something that could previously occur by telephone.
Physicians and abortion clinic staff scrambled to comply with the law. They reworked processes, patient flow and schedules. They trained staff. They learned the new state-mandated counseling script and reporting requirements.
The number of abortions provided in July in North Carolina — both medication and procedural — decreased by 31 percent from the previous month, according to the Guttmacher Institute. The new data shows 2,920 abortions were provided in July, which was 1,310 fewer than the 4,230 documented in June. The data does not account for self-managed abortions in the state — those occurring without in-person or virtual contact with the health care system.
North Carolina’s drop in abortions was higher than what occurred nationally, which saw a 7 percent decline in July.
This initial data in the aftermath of the new law demonstrates how North Carolina’s abortion restrictions make it harder for patients to obtain care and providers to offer it. That’s in line with what abortion providers say of their experiences.
While the drop is steep, it could have been far worse if all involved in providing abortion care had not adapted so nimbly, said Matt Zerden, Planned Parenthood South Atlantic’s associate medical director and an abortion provider.
“In some ways, it’s really remarkable that it only went down 31 percent,” Zerden said.
“We worked harder,” Zerden continued. “We had to create processes. Our health care team showed up and they did the best they could and they were really thoughtful and evolved with information as it came out to then say, ‘OK, what about the next clinic? Let’s restructure things a little bit so that we can see patients quicker, better, more and it still allows us to be compliant with the laws.”
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Amber Gavin, vice president of advocacy and operations at A Woman’s Choice, an abortion provider with three clinic locations in the state, said the law forced an overhaul of clinic operations.
“Especially in the first few weeks, the first month, it was like every day something was changing,” Gavin said. “The fact that we didn’t have this mass exodus is really wild, honestly, because it was so much turmoil and so much confusion.”
Gavin said A Woman’s Choice reworked patient flow so that staff are essentially running two separate clinics at each site. In the morning, staff are primarily focused on handling pre-procedure requirements, like state-mandated counseling, ultrasounds and lab work. Later in the day, patients having either medication or procedural abortions come into the clinic.
It’s an intricate balance of accommodating the increased patient volume of people in and out of the clinic, especially given the ramped-up pressure of the reduced time frame allowed for abortion procedures to take place in the state, Gavin said.
Planned Parenthood South Atlantic has experienced similar challenges, Zerden said. The same staff are having to complete twice as many appointments to provide abortion care for the same number of patients.
Zerden said in July, when Planned Parenthood South Atlantic provided fewer abortions than the previous month, the number of visits for abortion care increased by 70 percent.
“Every patient who’s going to receive an abortion has to come through the doors twice, get checked in twice, have an encounter in a medical record system twice — all the things,” Zerden said. “It’s an enormous amount of resources.”
For both providers and patients, Zerden added, it’s time-consuming and resource-draining for medically unnecessary work.
“When they’re there twice, it’s just occupying minutes, space and capacity that we can’t be delivering other care,” Zerden said. “All the care that we provide at Planned Parenthood South Atlantic is necessary and in short supply so it just makes everything more limited.”
North Carolina’s new abortion law creates additional hurdles for patients — some that can be insurmountable.
Many North Carolinians need to drive long distances — now twice — to reach one of the state’s 14 abortion clinics spread over nine counties. It necessitates extra time off work, travel, hotel stays and child care costs.
“The two-visit process is such an imposition and such a hardship for patients and frankly for the patients who can least afford the time off work, the child care that you have to arrange for, the travel,” Zerden said. “It’s really been devastating.”
Settling into new norm
Abortion providers all say July presented the steepest learning curve. Now, three months after the law has taken effect, abortion providers have settled into a new routine.
However, Amy Bryant, an OB-GYN and abortion provider in the Triangle, said that the new hurdles aren’t improving patient care or outcomes.
“I can say pretty definitively that none of this has resulted in higher quality medical care for our patients,” Bryant said, referring to Senate Bill 20, the new abortion law passed by state lawmakers less than 48 hours after the 47-page bill was unveiled in May.
It took abortion providers adjusting to the new requirements to realize how much better abortion access in North Carolina was just months ago.
“I can’t tell you how many times I’ve sat in clinic trying to figure out someone’s care — or been in a conversation with someone about someone’s care — and just had to navigate all of these new challenges and just really thought, ‘Wow, I had no idea like how much easier it was before and how many more challenges there are for patients now,’” Bryant said.
Beverly Gray, an OB-GYN at Duke Health who provides abortion care, agrees. She’s seen how restrictions have grown and abortion access has diminished.
“We’re moving through the grief of this new law and finding a path forward,” Gray said. “I see patients who are just incredibly grateful every single day — that are grateful that we’re still finding the best way possible to provide them care within the constraints of the law.”
Gray said patients often don’t have the same reference point she has. They don’t know how much harder access has gotten — how many more hoops have been added — and they go to great lengths to make it to their appointments.
Others can’t get the abortion care they want. Gray said turning people away from care — both North Carolinians and out-of-state residents — who do not meet North Carolina’s criteria for abortion is a daily occurrence.
States in the Southeast have some of the most restrictive abortion laws in the country. Laws in one state have cascading effects on others, said Molly Rivera, Planned Parenthood South Atlantic’s spokesperson.
North Carolina showcases this. North Carolina was considered an abortion safe haven after the Dobbs decision in June 2022 because the state did not take immediate action to restrict the procedure, while other states did. This resulted in many abortion seekers from nearby states such as Georgia, Tennessee and West Virginia traveling to North Carolina for care, bringing a surge in volume. In September, Guttmacher Institute researchers reported a 55 percent increase in abortions in North Carolina in the first six months of 2023 compared with 2020 data.
But now North Carolina is a less desirable place to seek care due to the constraints of the law. Abortion providers are seeing patients bypass North Carolina for states with less restrictive laws, even if they are farther away. Others may not have the resources to travel beyond their home state for care.
“The options narrow more and more for people in terms of where they can go,” said Guttmacher Institute data scientist Isaac Maddow-Zimet, who leads the organization’s Monthly Abortion Provision Study project. “The obstacles are mounting so much, and they’re cumulative.”
For some, Rivera said Virginia may be the most desirable nearby state since abortion is allowed there through the second trimester. Additionally, there is no state-mandated counseling or waiting period.
Over the past months, Rivera said Planned Parenthood’s health centers in Virginia have been able to add some capacity to see more people from out-of-state, especially North Carolinians.
“But that’s still not proportional to the need,” Rivera added. “There’s just no way a single state can absorb their normal patient load, but then also North Carolinians, South Carolinians and other people across the region. In addition to that, Virginia is in a politically tenuous situation.”
And those working in reproductive health care expect abortion access will continue to shift as lawmakers introduce new laws.
“I think it’s really frustrating that patients who live in different states or even different ZIP codes have access to totally different care,” Gray said. “That’s just never going to be fair.”
Tell us your story about abortion access
NC Health News will be continuing to cover the effects of increased abortion restrictions in the months ahead and the best way for us to do that is with your help — hearing concrete examples of how you are navigating the new law. Have you been affected by new abortion restrictions as a medical professional or a patient? NC Health News is interested in hearing your experience.