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The woman, dressed in a sweatshirt and sweatpants, just out of the recovery room after her abortion, was eager to get back to her two children, who had spent the day feeding cows and pigs on their great-aunt’s farm. In her mid-thirties, she had not intended to become pregnant, and knew immediately that she wanted an abortion. But she lives in a rural part of South Dakota, where nothing about abortion is immediate, or easy. The state’s only clinic, operated by Planned Parenthood, is in Sioux Falls, three hours from her home. It took four weeks to get an appointment. Because of the waiting period imposed by the state legislature, she had to make two round trips in four days to undergo the ten-minute procedure.

In fact, the woman who asked not to be identified had not wanted a surgical abortion at all. When she learned that she was pregnant, in early February, another option seemed more appealing: medication abortion. Long approved by the Food and Drug Administration, and safer than Tylenol, the two-pill regimen can, in many states, be prescribed by a doctor via a telemedicine consultation, sidestepping the need to visit a clinic, and can be taken at home, insuring privacy. The American College of Obstetricians and Gynecologists has written that patients can have a safe medication abortion “with a high level of patient satisfaction,” and that in-person visits are not medically necessary.

In South Dakota, where reproductive rights are constrained by some of the strictest laws in the country, medication abortion is being targeted by Republican governor Kristi Noem, who wants to “undermine and remove” Roe v. Wade and outlaw abortion completely. ” Last fall, she banned telehealth appointments for medication abortion, and prohibited the pills — mifepristone, to block progesterone, and misoprostol, to cause uterine contractions — from being delivered by mail or courier. Follow-up regulations issued by the state health department would require a patient to travel three times to a clinic — first to meet with a doctor, and then to receive each pill, all within five days

The woman I met at the clinic could not envision making so many trips — leaving her job and her children, and relying on a car that needed repairs. “I mean, living so far away, it just wasn’t going to work that way, that’s for sure,” she told me. After settling on the surgical procedure, which required two trips, she made the first appointment. Her brakes gave out on the drive home, forcing her to scramble to borrow a car. She had called Planned Parenthood to see if she could postpone her procedure by a day, but learned that the clinic only offers abortions one day a week. “When I called, they’re, like, ‘Well, we could send you to Minneapolis or Omaha,'” she said. “I’m, like, I can hardly get to Sioux Falls.”

Medication abortion is emerging as the next battleground for reproductive rights, particularly as laws governing surgical abortion grow ever less forgiving, and a conservative Supreme Court considers significantly weakening, or removing, constitutional protections guaranteed by Roe, which have been in place for half a century . By one preliminary estimate, fifty-four per cent of US abortions were performed via medication in 2020, up from thirty-one per cent just six years earlier. In the three months after Texas passed SB 8, which banned abortions after six weeks, requests for the pills through an organization called Aid Access nearly tripled. At least eighteen states allow a pregnant person to confer with a doctor by video and receive pills through the mail or from a pharmacy. The pills are also readily available on the Internet. Advocates say the method could ease the burden, and the expense, in places like South Dakota, where the single Planned Parenthood clinic lies near the eastern edge of a state more than twice the size of Ireland.

Ninety-five-per-cent effective until about nine weeks into a pregnancy, medication abortion was approved by the FDA in 2000, when the pill was known as RU-486. It was made available in 1988, in France, and is now legal in more than sixty countries. Despite a growing clinical record showing that trained nurse-midwives could safely guide women through a medication abortion, restrictions in the United States have steadily intensified. In 2020, Senator Ted Cruz, the Texas Republican, along with nineteen other senators, called on the FDA to remove the pills — which, they said, were “designed and intended to kill preborn children” —from the American market. The following year, as the pandemic wore on, the FDA expanded access, eliminating a requirement for in-person appointments.

But without federal legislation protecting abortion rights — Senate Republicans blocked the latest effort, on February 28th — the rules are set in state capitals. Elizabeth Nash, who monitors state laws for the Guttmacher Institute, a pro-choice think tank, told me that, in 2021, eight states adopted restrictions around medication abortion. “This is about eliminating a particular method of abortion on the march toward a total ban,” she said. Noem, whose chief of staff doubles as her “unborn-child advocate,” is at the vanguard. On Wednesday, she signed a bill that would upgrade the three-visit requirement from regulation into law, and would also make it a felony to prescribe abortion pills without a state license. The law, she said, would protect mothers and the unborn, because “abortion has two victims.” Noem had already been sued, in January, by the ACLU and Planned Parenthood, which argued that the health department’s three-visit rule violated the “undue burden” test established thirty years ago in Planned Parenthood v. Casey. Many patients, the suit contends, would be stopped from returning to the clinic by problems with transportation, duties at work or home, or travel costs. To require three visits for a medication abortion is “unprecedented in the United States,” Stephanie Amiotte, a legal director with the ACLU, told me.

One of the plaintiffs in the lawsuit is a doctor named Sarah Traxler, who flies to Sioux Falls about once a month from her home in Minnesota to see patients and perform abortions. A security guard meets her at the airport, drives her to the clinic, and escorts her inside, through a door made of bulletproof glass. Traxler, who is the chief medical officer for Planned Parenthood across a five-state region, is part of a rotation of out-of-state doctors who staff the clinic in Sioux Falls. No obstetrician-gynecologist who lives in South Dakota will work there, out of principle or fear. “It’s scary to think about going back to a place where people aren’t going to have agency over their bodies,” Traxler said. “And, you know, prior to Roe v. Wade, people died all the time.”

On a recent week, I met Traxler at the one-story clinic, where windows are situated high on the walls, and cameras monitor the movements of patients and protesters. There were six abortions scheduled. Traxler’s work is tightly choreographed by the dictates of state law. On what she refers to as Day One, she asks patients a series of questions and directs them to an ultrasound machine, before passing out state-mandated information about abortion. It used to be that a medical staff member could lead patients through the ultrasound and information phase, but, since 2018, the state has required a doctor to perform these roles. The doctor asks the patient to rate her certainty about having abortion on a scale of one to ten; the patient must be told that “the pregnant woman has a relationship with that unborn human being” and that abortion will terminate a human life. By law, the doctor must ask whether abortion conflicts with the patient’s religious or personal beliefs and relay the patient’s name and address to a “pregnancy help center,” which is typically designed to counsel against terminating a pregnancy.

Day Two, which is when Traxler performs the surgical abortion or dispenses the medication, happens seventy-two hours later, in accordance with a required waiting period. Weekends and holidays don’t count; a patient could not visit the clinic on a Friday and have an abortion on Monday. (Planned Parenthood staff note the exact minute on Day One when the patient signs the forms indicating that she wants to go through with the abortion. Not until that minute, three business days later, will the process begin.) Both visits must take place with the same doctor. On many occasions, a patient Traxler met on Day One has been prevented by a snowstorm or other calamity from returning on Day Two, or Traxler has been stranded in Minnesota because a plane could not fly. The clock then starts over, and the patient must go through the Day One procedures anew.

Traxler grew up in Louisiana, in a Southern Baptist home, “with the mentality that abortion was wrong. Abortion was not something that was supported by my peer group or my church. ” After college, she moved to Texas, where she worked with homeless young people, and saw the importance of reproductive health care when she met addicts who were engaging in survival sex. Those experiences, and the abortion story of a close friend, persuaded her to go to medical school so that she could provide them. When Traxler first learned of Noem’s Day Three rule, requiring a patient to return to the clinic to receive the second pill, she found herself wondering if a time would come when doctors determined to serve their patients would feel obligated to ignore the rules they saw. as punitive: “At what point do we start breaking the law? Would I ever do that? ” Her question remains theoretical, for now. On February 8th, U.S. District Judge Karen E. Schreier blocked the regulation from taking effect. There was a “no rational basis” for the extra visit, she wrote, and “there is a public interest in protecting the right to choose an abortion.” (The state is appealing the decision.)

Even without Day Three, significant numbers of South Dakotans seeking abortion struggle to get one. One reason is poverty. Fifty-six per cent of patients have a high-school education or less, which typically translates into jobs with low hourly wages and inflexible schedules, making it difficult for them to take time off for multiple trips to a clinic. One in four patients who receive a medication abortion in Sioux Falls travel more than a hundred and fifty miles round trip for each visit. “Many of Planned Parenthood’s patients rely on public transportation, ride-sharing or a borrowed car to reach the Sioux Falls clinic,” Schreier wrote. “Many abortion patients experience domestic violence, and some are unable to access health care without an abusive partner’s interference.”

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