At a routine ultrasound when she was five months pregnant, Hevan Lunsford began to panic when the technician took longer than normal, then told her she would need to see a specialist.
Lunsford, a nurse in Alabama, knew it was serious and begged for an appointment the next day.
That's when the doctor gave her and her husband the heart-wrenching news: The baby boy they decided to name Sebastian was severely underdeveloped and had only half a heart. If he survived, he would need care to ease his pain and several surgeries. He may not live long.
Lunsford, devastated, asked the doctor about ending the pregnancy.
"I felt the only way to guarantee that he would not have any suffering was to go through with the abortion," she said of that painful decision nearly three years ago.
But the doctor said Alabama law prohibits abortions after five months. He handed Lunsford a piece of paper with information for a clinic in Atlanta, a roughly 290km drive east.
Lunsford is one of thousands of women in the US who have crossed state lines for an abortion in recent years as states have passed ever stricter laws and as the number of clinics has declined.
Although abortion opponents say the laws are intended to reduce abortions and not send people to other states, at least 276,000 women terminated their pregnancies outside their home state between 2012 and 2017, according to an Associated Press analysis of data collected from state reports and the U.S. Centers for Disease Control and Prevention.
In New Mexico, the number of women from out of state who had abortions more than doubled in that period, while Missouri women represented nearly half the abortions performed in neighboring Kansas.
"The procedure itself was probably the least traumatic part of it," Lunsford said. "If it would have been at my hospital, there would have been a feeling like what I was doing was OK and a reasonable choice."
While abortions across the US are down, the share of women who had abortions out of state rose slightly, by half a percentage point, and certain states had notable increases over the six-year period, according to AP's analysis.
In pockets of the Midwest, South and Mountain West, the number of women terminating a pregnancy in another state rose considerably, particularly where a lack of clinics means the closest provider is in another state or where less restrictive policies in a neighboring state make it easier and quicker to terminate a pregnancy there.
"In many places, the right to abortion exists on paper, but the ability to access it is almost impossible," said Amy Hagstrom Miller, CEO of Whole Women's Health, which operates seven abortion clinics in Maryland, Indiana, Texas, Virginia and Minnesota. "We see people's access to care depend on their ZIP code."
Hevan Lunsford with her son's ultrasounds and footprints and handprints. Photo / AP
Nationwide, women who traveled from another state received at least 44,860 abortions in 2017, the most recent year available, according to the AP analysis of data from 41 states.
That's about 10% of all reported procedures that year, but counts from nine states, including highly populated California and Florida, and the District Columbia were not included either because they were not collected or reported across the full six years.
Thirteen states saw a rise in the number of out-of-state women having abortions between 2012 and 2017.
New Mexico's share of abortions performed on women from out of state more than doubled from 11% to roughly 25%. One likely reason is that a clinic in Albuquerque is one of only a few independent facilities in the country that perform abortions close to the third trimester without conditions.
Georgia's share of abortions involving out-of-state women rose from 11.5% to 15%, while North Carolina saw its share increase from 16.6% to 18.5%. North Carolina had one of the highest shares of out-of-state abortions in 2017. While both states have passed restrictive laws, experts and advocates say they are slightly more accessible than some of their surrounding states.
In Illinois, the percentage of abortions performed on non-residents more than doubled to 16.5% of all reported state abortions in 2017. That is being driven in large part by women from Missouri, one of six states with only a single abortion provider.
Even that provider, in St. Louis, has been under threat of closing after the state health department refused to renew its license.
Missouri lawmakers also passed a law this year that would ban almost all abortions past eight weeks of a pregnancy, but it faces a legal challenge.
About 16km from St. Louis, across the Mississippi River, is the Hope Clinic in Granite City, Illinois, which has seen a 30% increase in patients this year and has added two doctors, deputy director Alison Dreith said.
About 55 percent of its patients come from Missouri, and it also sees women from Indiana, Kentucky and Ohio. All those states have mandatory waiting periods to receive an abortion, a requirement Illinois does not have.
Dreith called it a scary time for women in states with highly restrictive laws and few clinics."The landscape that we're seeing today did not happen overnight, and it was not by accident," she said.
And Illinois isn't the only place Missouri women are heading for abortions.In 2017, Missouri women received 47% of all abortions performed in Kansas. That is in large part because the only access to the procedure throughout western Missouri, particularly the greater Kansas City area, is across the state line in Overland Park, Kansas.
Between 2011 and May 31 of this year, 33 states passed 480 laws restricting abortion, according to the Guttmacher Institute, a research organisation that supports abortion rights.
In 2019 alone, lawmakers approved 58 restrictions primarily in the Midwest, Plains and South — almost half of which would ban all, most or some abortions, the group said.
The most high-profile laws, which face legal challenges that could eventually test the U.S. Supreme Court's Roe v. Wade decision, would ban abortion after a fetal heartbeat can be detected — as early as six weeks.
Advocates say that if the Supreme Court upholds the latest restrictions, it will become more common for women to seek an abortion in another state.
"The intent of these lawmakers is to completely outlaw abortion and force people not to have abortions. But in reality, it pushes people farther and wider to access the care they want and need," said Quita Tinsley, deputy director of Access Reproductive Care Southeast.
ARC Southeast is part of the National Network of Abortion Funds, a collective of 70 abortion support groups for women in six Southeast states. Some provide money to women to pay for abortions, while others also help with transportation, lodging and child care.
A third of women calling the group's hotline for help end up traveling out of state for abortions, Tinsley said. Many choose Georgia because it's convenient to get to and considered slightly less restrictive than some other states in the South.
In Georgia, which has a mandatory waiting period, a woman is not required to come to a clinic twice, like they are in Tennessee. But if Georgia's new fetal heartbeat law survives a court challenge, it would have one of the earliest state-imposed abortion bans.
That would force many women to go even farther from where they live to terminate their pregnancies.
Of all states, New Mexico has seen the biggest increase in the number of women coming from elsewhere for an abortion — a 158% jump between 2012 and 2017, according to AP's analysis.
The New Mexico Religious Coalition for Reproductive Choice helps an average of 100 women a year but is on track to assist 200 this year. Some of its 55 volunteers open their homes to women coming from out of state.
Executive director Joan Lamunyon Sanford said her group is doing what faith communities have always done: "Care for the stranger and welcome the traveller."
Lamunyon Sanford said the need is growing as barriers increase and women are unable to access care where they live.
"They have to figure out so many details and figuring out how they are going to get the funding for everything," she said. "Sometimes it's just too much. And then they become parents."
The coalition helped Beth Vial, who didn't learn she was pregnant until she was six months along after chronic medical conditions masked her symptoms.
Beth Vial, who didn't learn she was pregnant until 26 weeks after chronic medical conditions masked her symptoms. Photo / AP
As a 22-year-old college student living in Portland, Oregon, Vial was beyond the point when nearly every abortion clinic in the country would perform the procedure.
Vial's only option for an abortion was New Mexico, where a volunteer with the New Mexico Religious Coalition for Reproductive Choice drove her to and from the clinic in Albuquerque and brought her meals.
The support she received inspired her to join the board of Northwest Access Abortion Fund, which helps women in Oregon, Washington, Idaho and Alaska.
"To have people I didn't even know support me in ways that I didn't even really know I needed at the time was unlike anything I have ever experienced," said Vial, now 24. "It has encouraged me to give back to my community so other people don't have to experience that alone."
Abortion opponents say the intent of laws limiting the procedure is not to push women to another state but to build more time for them to consider their options and reduce the overall number of abortions.
"I have been insistent in telling my pro-life colleagues that's all well and good if the last abortion clinic shuts down, but it's no victory if women end up driving 10 minutes across the river to Granite City, Illinois, or to Fairview Heights," said Sam Lee, director of Campaign Life Missouri and a longtime anti-abortion lobbyist.
Anti-abortion activists also hope a broader cultural shift eventually makes these issues disappear.
"We are seeing this trend toward life and a realisation of what science tells us about when life begins," said Cole Muzio, executive director of the Family Policy Alliance of Georgia who advocated successfully for new abortion limits there. "Just because something is legal does not mean that it is good."
Before the recent wave of legislation focused on limiting when an abortion can be performed, opponents largely worked to regulate clinics. Critics say those regulations contributed to more clinics closing in recent years, reducing access to abortion in parts of the country and pushing women farther for care.
Texas lost more than half its clinics after lawmakers in 2013 required them to have facilities equal to a surgical center and mandated doctors performing abortions have admitting privileges at a nearby hospital.
Joan Lamunyon Sanford, executive director of the New Mexico Religious Coalition for Reproductive Choice. Photo / AP
Even though the US Supreme Court struck down key provisions of the law in 2016, most clinics have not reopened.
Candice Russell was among those who felt the impact. When she sought an abortion in Dallas in 2014, she was told she would have to wait more than two weeks because of an influx of patients from other parts of Texas where clinics had closed.
She feared she would not be able to miss work for back-to-back appointments, required under Texas' mandatory waiting period, so she told the bar where she worked that a relative died and took out a payday loan to buy an airplane ticket to California. She had the procedure the next day.
"Even though I had to take on that horrendous loan and entered a debt spiral that lasted until about two years ago, I am really, really lucky," said Russell, now 36 and working as deputy director of the Yellowhammer Fund, which helps women in Alabama seeking abortions. "There are a lot of people who just can't do that. They can't get on a plane and fly 1,500 miles for an abortion."
Nationwide, 168 independent abortion clinics have closed since 2012, and just a handful opened over that time, according to the Abortion Care Network, a clinic advocacy group.
Some resulted from providers retiring and an overall decline in unplanned pregnancies, but advocates say many shut down because of restrictive laws.
"It's not about safety of patients," said Nikki Madsen, executive director of the Abortion Care Network. "It's about closing clinics."
For Lunsford, it took two years before she could begin managing the grief of losing her son, compounded by the hurdles she faced to carry out that painful decision — the drive to Atlanta, staying in a hotel and going to a clinic with doctors she didn't know.
Lunsford, now 31, said she thinks about how she couldn't hold her baby, an intimate goodbye that might have been possible if she had the abortion at a hospital. Before she left Atlanta, she asked the clinic's staff to use the inkpad and paper she brought so she could keep her son's footprints and handprints.
"Most of the laws I navigated, there was no reason for them," she said. "None of them prevented my abortion. It just made it where I had to travel out of state."
