Barriers to abortion access may exacerbate each other, creating significant difficulties for patients seeking care, according to “Barriers to Abortion Care and Their Consequences for Patients Traveling for Services: Qualitative Findings from Two States,” by Jenna Jerman et al., of the Guttmacher Institute.

In 2015, the authors interviewed 29 abortion patients in Michigan and New Mexico who had traveled either across state lines or more than 100 miles within the state to obtain abortion services. All of the respondents reported that they had experienced multiple barriers while seeking care. On the basis of their responses, the researchers identified five categories of barriers: travel-related logistical issues, system navigation issues, limited clinic options, financial issues, and state or clinic restrictions.

As a result of these barriers, respondents reported experiencing three types of negative consequences: delays in accessing care, negative mental health impacts, and considering ending the pregnancy outside of a clinic setting. The authors found no direct link between any one barrier and any one consequence. Rather, they found that the intersection of multiple barriers had a compounding effect.

“Our respondents’ experiences demonstrate how individual barriers—which might be separately surmountable—can weave together to obstruct access to abortion,” said Jerman. “When abortion becomes inaccessible or unavailable, the solution is not as simple as ‘just going elsewhere.’ As barriers multiply, some patients must go to ever greater lengths to obtain the health care they need.”

The authors suggest that any additional barriers to accessing services may be particularly significant for poor and low-income patients, who represent 75% of those having abortions. Raising money to access a procedure often takes time and can delay the procedure. As a pregnancy progresses, the cost of an abortion increases and fewer providers offer care, so some patients may need to travel longer distances or cross state lines to access services. For many, traveling presents further financial and logistical obstacles, including the need to arrange transportation and lodging, take time off from work and arrange for child care.

Several respondents noted that travel itself exacerbated the impact of barriers and increased the stigma associated with having an abortion. As one woman observed, “It didn’t hinder me from [having an abortion]; I didn’t say, ‘Oh, I’m just going to keep it now.’ I just had to go all the way out of my way. It made it so much worse for me.” Another respondent commented that having to travel across state lines to access abortion care “makes you feel like you’re doing something bad.…It just makes you feel kind of guilty for no reason.”

Jerman notes that restrictive state laws, while a barrier in their own right, also worsened the other obstacles respondents encountered when seeking abortions. In 2016, the U.S. Supreme Court reaffirmed the constitutional right to abortion in Whole Woman’s Health v. Hellerstedt, clarifying that abortion restrictions are unconstitutional if the real-world burdens they impose on women outweigh any proven, tangible benefits. As part of its analysis of the real-world impact of Texas abortion restrictions, the Court found that increased driving distances interact with other burdens (such as those caused by clinic closures) to create an unconstitutional “undue burden.” Future analyses of undue burden could benefit from this study’s findings by examining abortion restrictions as part of a system of barriers and consequences, not only as isolated phenomena.

“This study provides further evidence of the many barriers that accumulate for patients seeking abortion care,” said Megan Donovan, Guttmacher policy expert. “In order to understand the full impact of state restrictions, individual policies should be evaluated as part of a broader hostile abortion landscape.”