Twelve weeks into a pregnancy that no one in her rural Pennsylvania hometown knew about, Sarah Hammond began driving to obtain an abortion.

There was no clinic in the 23-year-old’s small town in York County, where she worked on the floor of a manufacturing plant to pay off college loans. Her partner had recently been deployed overseas. And the pregnancy, she had just learned, was certain to end in a miscarriage. An abortion would let her control how her body went through the experience.

But first, she had to drive herself to the closest clinic — an hour and a half round-trip. Pennsylvania law then required her to listen to a doctor read the alternatives and make the trek again after a 24-hour mandatory waiting period.

“I kind of blanked out,” she said. “It’s a nightmare when you’re going through an experience like that.” Hammond didn’t speak publicly about her experience until more than two years later, during a 2020 run for public office.

In the vast stretch of Pennsylvania between Pittsburgh and Philadelphia, it can be almost as hard to get an abortion as in Mississippi, the state at the center of a leaked U.S. Supreme Court draft decision that appears poised to overturn nationwide abortion rights. Although Pennsylvania has never enacted restrictions as stringent as Mississippi’s ban on abortions after 15 weeks, the laws on the books still have effectively wiped out access in much of the commonwealth. More than 90% of abortions take place in eight of Pennsylvania’s 67 counties; only 14 counties even have an abortion provider.

Though opponents of abortion say such laws are necessary to ensure safe medical care, Pennsylvania has whittled away access to abortions and made the process burdensome for patients and providers.

Living near a clinic is useless for those who can’t afford hundreds of dollars for a medical service not covered by Medicaid or most private insurance plans. Those who can find the money must go through mandatory counseling, then wait 24 hours. Minors need a legal guardian’s permission. And everyone must complete tests that medical experts consider unneeded for most patients.

This is the legacy of Pennsylvania’s central role in a decades-long legal debate over abortion rights.

“If you’re someone who doesn’t have a lot of money, who is limited in your support system, living in a rural area, you’re a minor or part of a historically marginalized community — those burdens are insurmountable,” said Roxanne Sutocky, director of community engagement for the Women’s Centers, which operates abortion clinics in Philadelphia, Cherry Hill, Connecticut, and Georgia.

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Pennsylvania’s legacy of abortion restrictions

Pennsylvania was among the first states to restrict access to abortion after the U.S. Supreme Court affirmed it as a right in Roe v. Wade. The 1982 Pennsylvania Abortion Control Act imposed the mandatory counseling, 24-hour waiting period and parental consent for minors, and also required spousal notification for married people.

A Supreme Court ruling in a case brought by Planned Parenthood against then-Pennsylvania Gov. Bob Casey Sr. in the 1990s upheld all but the spousal notification requirement, creating the legal framework for increasingly more restrictive state laws that followed elsewhere in the country.

At least 14 states have since passed bills that ban abortion after six weeks and 26 states are “certain or likely” to immediately ban abortion if Roe is overturned, according to analysis by the Guttmacher Institute, which advocates for abortion rights.

Pennsylvania never went so far, but has forced clinics to close by enacting building and operating requirements that clinic operators say are difficult to meet.

Hallways must be a certain width, exam rooms must be a specific size; there are requirements about parking spaces, and front door awnings. Building a clinic or renovating an existing medical building to compliance costs $2 million to $5 million, said Melissa Reed, CEO of Planned Parenthood Keystone, which operates reproductive health clinics in eastern and southern Pennsylvania.

All consultations and procedures must be performed by a doctor ― even telehealth medical abortion appointments, when a doctor watches on video as the patient swallows a pill to end a pregnancy.

After many of these rules took effect in the 2000s, the number of abortion clinics declined to 18 clinics in 2017. There are currently about two dozen abortion providers, a combination of clinics and hospital-owned centers, according to a list maintained by Abortion Liberation Fund of PA, which helps pay for abortions. The majority are concentrated around Philadelphia and Pittsburgh, leaving 53 counties without an abortion provider.

Following the newly leaked court opinion, Democratic Gov. Tom Wolf vowed to protect the right to abortions as long as he is in office. But his term ends in January, and Pennsylvania’s Republican-led legislature is already lining up bills to roll back abortion rights.

“[T]here’s plenty more heavy lifting that needs to be done at the state level to help usher in the post-Roe generation,” said State Rep. Kathy Rapp, majority cochair of the Pro-Life Caucus, who represents northwestern Pennsylvania.

Patients burdened by waiting periods, cost, location

Abortion — and accessing an abortion — can be difficult for anyone. But the barriers tend to be most challenging for Black, Latino, and Indigenous people, who are already more likely to struggle with access to health care, said Rachel Villanueva, a New York-based obstetrician and president of the National Medical Association, a professional association for Black doctors.

“It’s the population that already lacks access to quality care that will be disproportionately suffering,” Villanueva said.

In Pennsylvania, Black people are almost seven times as likely as white people to seek out abortions, health department statistics show.

About 64% of people who had an abortion in Pennsylvania already had at least one child, and 88% were unmarried, according to the most recent report from the Pennsylvania Department of Health.

With clinics so sparse in Pennsylvania, the 24-hour wait often requires an overnight stay, which can mean lost wages, lodging expenses, and child care — all on top of the $450 to $550 the procedure costs.

Medicaid, the publicly funded health insurance program for low-income families, does not cover the procedure. Several patient advocate groups are fighting in court to change that.

“The financial burdens are overwhelming for many folks,” said Elicia Gonzales, executive director of the Abortion Liberation Fund of PA.

Medical abortion, which uses oral and vaginal medication, has become as common in Pennsylvania as abortions performed surgically in clinics. Many patients prefer this option because they do not need to travel to a clinic, as these appointments can be held virtually.

But first Pennsylvania requires blood and urine protein testing — lab work that is not medically necessary for the vast majority of patients, said Sutocky of the Women’s Centers.

The organization’s Cherry Hill clinic orders these tests only when warranted by a patient’s medical history.

“Our Philadelphia and Cherry Hill centers are 15 minutes apart, but worlds away from each other when it comes to the regulatory oversight and impact on providers and patients.”

Roxanne Sutocky, director of community engagement for The Women’s Centers operating abortion clinics in Philadelphia and Cherry Hill

New Jersey does not have a waiting period or require family notification, and the state’s Medicaid program can pay for abortions. The state also allows medical professionals other than doctors to perform abortions.

Earlier this year, Gov. Phil Murphy signed into law the right to have an abortion.

“Our Philadelphia and Cherry Hill centers are 15 minutes apart but worlds away from each other when it comes to the regulatory oversight and impact on providers and patients,” Sutocky said.

From difficulty to strength

After her abortion in 2017, Hammond has thought often about the distance she traveled, the cost, the fact that she wasn’t able to take more than a day off from work to recover and cope. The pregnancy was unplanned, and Hammond didn’t feel ready to be a parent, but more important, she had already begun to miscarry. The ability to get a surgical abortion was emotionally and physically more palatable than waiting for her pregnancy to end naturally.

What bothers her most, she said, is that the experience is even harder for people with fewer resources than she had.

Hammond began to talk about her experience while campaigning in 2019 as the Democratic candidate for Pennsylvania’s 11th Congressional District, which represents Lancaster County and parts of York County. She lost the election, but has continued to advocate for women’s rights by sharing her story at rallies and Planned Parenthood events. Speaking out was scary at first, but her voice grows stronger every time she tells her story.

“I draw strength from it now,” she said.