Notes from the rural/urban divide: Abortion

Approximately 20 percent of people in the US live in rural communities. These communities are incredibly culturally rich and diverse, despite the slew of stereotypes surrounding rural life, but they do have limitations, and one of the most severe involves restrictions on available services. Those restrictions exist for a variety of reasons: Insufficient population to support a given service, expense, lack of interest in providing it, feasibility. It’s why rural areas often lack health care specialists, why our roads are worse, why public transit is scarce.

These things aren’t the result of some kind of perverse hatred of public services in the rural corners of the United States. When your population is small and scattered, the kinds of resources available shrink. There aren’t enough people to support a full time neurologist, for example. Comprehensive public transit wouldn’t have enough customers to be be practical. Multiple businesses providing a similar service likely wouldn’t thrive, so there’s less competition in pricing, sometimes driving up costs for basic goods and services. Some things aren’t available at all, because it’s impossible to make a go of it.

As the United States discusses the crackdown on access to reproductive health care, especially abortion, people are sort of vaguely talking about rural areas, but they aren’t talking about them enough. It’s important to specifically discuss the issues that face rural communities when it comes to abortion access, because it’s a serious issue, but it also has to be viewed with some nuance. Simply folding rural communities into the general abortion discussion doesn’t work, and won’t work.

The number of standalone abortion clinics in the United States was small even before the right got cranked up, and now it’s even smaller. Many rural communities lack fully equipped hospitals, let alone OB/GYNs who perform abortions. In conservative states like Texas and Iowa, it’s functionally impossible for rural patients to access abortion services in their communities. There are a whole set of intersecting reasons for this, and they’re very worrying.

Many conservative states are also highly rural, which means that when these states crack down on abortion access, rural USians are disproportionately affected. People often jump to the assumption that the highly rural nature of conservative states is what causes them to be conservative, but that’s an unjust stereotype about rural people. Lawmakers in these areas predominantly come from suburban and urban areas, and there’s where a lot of the agitation to restrict abortion access is rooted.

But because rural communities have limited resources, they get hit hard by abortion restrictions. Standalone clinics operating in rural areas cannot afford upgrades to comply with TRAP laws, for example. Hospitals, meanwhile, are thin on the ground — a really big problem when states pass laws requiring physicians to have admitting privileges at a hospital within a set (usually small) distance. So even as community clinics are forced out, rural people may not have a hospital to turn to. Or, if they do, that hospital might not offer abortion services.

And this isn’t a problem limited to conservative states. California is as blue as they come, and heavily stereotyped for leftist values, but people may be surprised to learn that outside major metropolitan areas, abortion is challenging to access. And that’s without the highly restrictive laws other states are using in an attempt to legislate abortion into oblivion. Many rural communities can’t support abortion clinics, and may only have one care provider offering abortions at a hospital which could be 70 or more miles away — and when that care provider retires, or the community agitates over abortion services, that hospital may stop providing abortion care. Which means traveling even further to obtain access.

Poverty is a big problem in rural communities. It’s not necessarily easy for people to travel, as they may not have the resources they need to make a trip somewhere for abortion care — it might require a day, or more, of traveling, which requires finding a place to stay. That means taking time off work, gathering funds not just for the procedure but for travel, lodging, and food, and trying to find someone to serve as a companion (lots of abortion clinics and hospitals won’t release people after procedures if they don’t have someone picking them up). In states with restrictive waiting periods, people have to take even more time off to get an abortion.

This can result in forcing people to wait — they may know that they want to terminate pregnancies, but have trouble gathering funds, getting time off, and making arrangements. The window in which a medication abortion is an option can come and go, forcing people to get more invasive, and costly, surgical abortions. What should be a simple matter of visiting a local health clinic to get a medication abortion can turn into a massive and horrific ordeal. That ordeal can be particularly awful for people experiencing miscarriages who need D&Cs and other miscarriage care — if no one trained in D&Cs is available locally, people may be traveling for hours to get health care for a traumatic event that has serious health implications, including the risk of septicaemia, death, and infertility.

When we talk about abortion access, it’s important to talk in broad strokes about the cultural issues contributing to lack of abortion access. But we also need to drill down and get into the specific needs of all kinds of communities in the United States, because the issue isn’t uniform. The problems facing rural communities aren’t the same as those in suburbia and urban areas, and we need to acknowledge that.

Image: Balbao 2014, Denis Bocquet, Flickr