Soon after the election, President Donald Trump was asked what would happen if Roe v. Wade were ever overturned. His answer ― that women would simply have to “go to another state” if they lived in an area that outlawed abortion ― drew the immediate ire of reproductive rights advocates who understand the tremendous barriers that many women seeking an abortion already face, even with federal protections.

One of those barriers? In many parts of the country, there simply aren’t enough clinics to serve women. It’s a situation that worsened last week when West Virginia’s second-to-last abortion provider, the Kanawha Surgicenter, quietly shuttered its doors. A handwritten note taped to its front door announced its closure along with a dumpster piled high with discarded office and medical equipment. 

West Virginia now joins a handful of states including Mississippi, North Dakota, South Dakota and Kentucky that have just one remaining abortion provider. (Arkansas is sometimes included on that list, because it has only one remaining surgical abortion provider, although there is another provider in the state that offers medical abortions, i.e. the abortion pill.) Kentucky’s second-to-last abortion clinic closed on Friday. 

That means that what sounds like a rare and extreme situation is now the reality in roughly one-tenth of the states in this country.

Reproductive rights advocates tend not to broadcast that statistic in part to help keep clinics and doctors safe. 

“It’s been known for many years now that the anti-choice movement uses that list to specifically target clinics,” Leslie McGorman, the deputy policy director of NARAL Pro-Choice America, the reproductive rights advocacy group, told The Huffington Post. “It really is kind of a safety mechanism to not have that number floating around there.”

Yet the “accidental consequence” of trying to protect providers, she said, is that many people have no idea how grave the shortage is in certain states.

“In most urban areas in the U.S., women have adequate access to abortion care,” said Vicki Saport, president and CEO of the National Abortion Federation, the professional association of abortion care providers. “Sometimes they may still have to travel for specialized care, for health reasons or for later care if they need it and it’s not available in their area. But most urban areas still have reasonable access to abortion care.”

“The problem lies when women are in more rural areas, or some of these states where there are only one or two providers,” Saport continued. Studies have shown that when women have to travel longer distances, they spend more money and find it more difficult to access care. And when women are denied abortions their mental health suffers. They are also far more likely to fall below the federal poverty line. 

The dramatic provider shortage in some states is a challenging problem to address simply because there are so many factors that drive providers to shut down.

Certainly, anti-choice legislation at the state level plays a significant role, particularly so-called “TRAP” laws, which stands for targeted regulation of abortion providers. States like Texas have attempted to require that abortion care providers get admitting privileges at local hospitals, which is often impossible. (The Supreme Court ruled last summer that it imposes an undue burden on women seeking abortion services.)

Others, such as Kansas and Virginia, have forced clinics to make expensive, medically unnecessary renovations, addressing details like the width of a hallway or janitor’s closet ― though some states have begun to roll those back after the Supreme Court decision.

“It’s the violence piece, the exposure piece, the relentless attacks by the anti-choice side, the political interference in licensure that all, taken together, is almost insurmountable for an abortion provider to stay open,” said Pomponio.

All of which means that when a provider decides it is simply too much, as was the case in West Virginia where the provider who had been commuting regularly from California reportedly no longer wanted to make the long trip, there is no one to take their place. And then women are the ones who suffer. 

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