New estimates of the number of abortions provided within the formal health care system show a decrease of 1,310 abortions in North Carolina in July 2023 compared with June. This 31% decline in facility-based abortions provided in one month—the largest of any state—follows the July 1 implementation of severe new abortion restrictions in the state, including a ban on abortions occurring after 12 weeks’ gestation and an in-person requirement for state-mandated counseling. The in-person counseling requirement is a medically unnecessary barrier that forces patients to make a separate trip to a health care facility at least 72 hours before their abortion. Previous state law included a 72-hour mandatory delay while allowing patients and providers to complete the first appointment by telephone.

The findings on North Carolina are part of the second round of data released by the Guttmacher Institute’s Monthly Abortion Provision Study, a new research initiative to track monthly estimates of medication and procedural abortions provided within the formal US health care system. Researchers had initially documented substantial increases in abortions provided in nearly all states bordering those where abortion had been banned in the first six months of 2023 compared with 2020—including a 55% increase in North Carolina. These findings indicated that large numbers of residents of states with abortion bans were traveling to neighboring states to receive abortion care—an option that is disproportionately unavailable to people of color, people living with low incomes and other marginalized groups already experiencing inequities in health care access. These new data offer a deeper understanding of the immediate effect on abortion access when harmful state policies are implemented.

Abortion Access in North Carolina Hit Hard

In a region already dominated by total abortion bans and early gestational bans, as well as other highly restrictive policies, North Carolina’s newest abortion restrictions seem to be having a severe impact. There were 4,230 abortions provided in the formal health care system in June and 2,920 in July—a decline of more than 30%, compared with a 7% decline nationally.

While North Carolina’s 12-week ban is undoubtedly limiting access for some, the new requirement that patients make two separate in-person visits for their abortion may be having an even wider impact. The two-trip requirement serves no legitimate medical purpose. Rather, it is a continuation of a decades-long anti-abortion strategy to impose onerous requirements that make it harder for patients to obtain care and for providers to offer it, even where abortion is legal. An additional visit to a provider might be a barrier to care that a person seeking an abortion simply cannot overcome, especially when an extra visit may entail taking time off work and paying for travel and childcare. In addition, the two-visit requirement means that North Carolina providers must schedule and staff twice the number of in-person appointments for the same number of patients to receive care. That work comes on top of adjusting to increased demand from patients traveling from nearby states with abortion bans and coping with a decline in reproductive health care providers in the state.

Abortion Counts Across the Southeast Shed Light on North Carolina Abortion Access

Guttmacher’s new data show no increases in abortions provided in neighboring or nearby jurisdictions (South Carolina, Virginia, the District of Columbia or Maryland) that would offset the more than 30% decline in North Carolina. This could indicate that some people who would otherwise have obtained an abortion within the formal health care system in North Carolina may have self-managed their abortion (for instance, by procuring abortion pills by mail) or may have been forced to remain pregnant. Notably, US-based online medication abortion provision to some states with an abortion ban began publicly in June under the protection of shield laws for providers in the originating state; it is possible this development could lead to fewer people needing to travel to receive abortion care. It may take some time to see how many patients in North Carolina will go this route, as the new abortion restrictions implemented in July also target out-of-state providers mailing abortion pills into the state.

The reality of dramatically reduced abortion access in North Carolina, while not immediately resulting in increased abortion counts in other states, is nonetheless likely having a regional impact. Since the US Supreme Court overturned Roe v. Wade in June 2022, travel to North Carolina has been an important option for patients living in nearby states where abortion has been banned or severely restricted, including Georgia, Tennessee and West Virginia. North Carolina’s requirement of two in-person visits, at least three days apart, is likely a major barrier that many people who would otherwise come from out of state to get an abortion are unable to overcome.

The Future of Abortion Access in North Carolina and the Southeast Is Uncertain

A number of factors make it difficult to predict how a decrease in abortions will play out in coming months. The large decline in abortions provided in North Carolina—and the smaller national decline—may to some degree reflect seasonal variations in when pregnancies, and thus abortions, occur. It also may not end up being a sustained decrease: future data collection may show that the steep drop seen in July lessens as patients and providers adapt to the new restrictions (though it is important to acknowledge that a rebound in abortion counts does not necessarily indicate that everyone who needs abortion care is receiving it). These new estimates for July showing a national decline may also indicate a decline in the ability of an overstretched and exhausted network of abortion funds, practical support groups and dedicated providers to meet the demand for abortion care and associated financial needs and logistics in such a hostile policy environment.   

In addition, continued regional disruption to abortion access—such as the six-week ban implemented in South Carolina on August 23—will affect patterns of abortion seeking in North Carolina and other neighboring states. Future data releases from the Monthly Abortion Provision Study will shed additional light on the impact of this policy and its ripple effects in other states.

Attacks on Abortion in North Carolina Began Years Ago  

North Carolina’s abortion laws are indicative of the broader chaos and confusion unleashed when the Supreme Court overturned Roe in 2022. Currently, 14 states ban abortion almost completely and several others ban abortion at early points in pregnancy, forcing patients to race against the clock to obtain care from a provider in those states. North Carolina already had made headlines in the past decade by enacting a series of restrictive abortion laws and by making continued investments in unregulated anti-abortion centers (commonly known as “crisis pregnancy centers”), many of which use deceptive tactics to deter people seeking abortion from getting the care they need. The following examples highlight the hostile climate anti-abortion policymakers have created in the state:

• 2011: The Woman’s Right to Know Act created a 24-hour waiting period and state-mandated counseling before an abortion, as well as an ultrasound requirement that was overturned in 2014. The law allowed the first counseling visit to take place by telephone.
• 2013: North Carolina used dubious political machinations to enact a series of abortion restrictions that both threatened to close down clinics and placed additional burdens on patients.
• 2015: The state enacted a 72-hour waiting period, mandating a longer delay in accessing care for no medically justifiable reason. This law allowed the first counseling visit to take place by telephone.
• 2019: A federal judge struck down the state’s 20-week ban that took effect in 1973.
• 2022: The same judge reinstated the 20-week ban in August, claiming his original ruling no longer stood without Roe in place.

In 2023, as states responded to the shifting legal landscape following the upending of Roe, North Carolina’s legislature suddenly had a Republican supermajority after a Democratic state representative changed her party affiliation. The abortion rights–supporting governor and the anti-abortion legislature clashed on abortion policy in the first half of 2023 and a package of new abortion restrictions ultimately became law after Gov. Roy Cooper’s veto was overridden. Despite a legal challenge, SB 20 took effect on July 1, moving an already-restrictive state policy climate to one even more hostile to abortion access.

The Monthly Abortion Provision study data showing a sharp decline in abortion care in the first month following the new law’s effective date point to an understanding that abortion bans and restrictions continue to place obstacles before people who need abortion care.