A. wanted a cheeseburger and to go home. She had made the three-hour trip from Indianapolis to Chicago a day earlier and had been at the hospital since 6:30 a.m., with an empty stomach, waiting to be taken into an operating room to have an abortion.
It was her second trip to Chicago in two weeks, and the third time she had tried to end her pregnancy.
She ordered abortion pills online in July, but they were ineffective. A few weeks later, after Indiana enacted a total ban on abortion, she made an appointment at a clinic in Chicago. But an ultrasound revealed that her placenta was growing abnormally, increasing the risk of bleeding. She was told she would need to have the procedure done at a hospital instead.
“This is not what I was expecting,” said A., 36, who asked to be identified by only her first initial. “I had an abortion before and it was a one-two kind of thing. I was out of the clinic in an hour.”
Abortions are extremely safe, but for women with certain pregnancy complications, it can be risky to take abortion pills or to have the procedure done in an outpatient clinic. The same is true for women with severe underlying or untreated health conditions, including asthma, diabetes, hypertension and hyperthyroidism.
For patients with these conditions seeking an abortion, having it done in a hospital is the safest option because of the ability to do emergency procedures, like blood transfusions. But a hospital procedure is often more onerous, expensive and time-consuming, especially since the Supreme Court’s decision last year to overturn Roe v. Wade.
“I know this is not open-heart surgery, but you’re being treated like it is,” A. said. “Mentally, it freaks you out.”
Nationally, about 3 percent of abortions occurred in hospitals before the Dobbs decision, usually in instances of fetal anomalies or high-risk pregnancies. In states with abortion bans, hospitals now perform the procedure in only the most limited cases. But in places like Illinois, hospitals are playing a larger role in abortion access as more patients travel to seek care.
“Hospitals have always had a role in abortion care, but hospitals have not always filled that role,” said Dr. Jenni Villavicencio, an OB-GYN and the interim director of public affairs and advocacy at the Society for Family Planning, a group that supports abortion rights.
“The spotlight on them is brighter now post-Dobbs because the number of places where people can access abortion has shrunk by almost half,” she added.
‘Sick people get abortions, and healthy people get abortions’
Dr. Laura Laursen belongs to a group of Illinois abortion providers who started meeting informally last year, anticipating the state would become a hub for abortion access for much of the Midwest and South.
In the months that followed, providers noticed that they were not only seeing more patients overall — abortions rose an estimated 69 percent in Illinois during the first half of 2023 — but also more patients with complex health issues that prevented them from having an abortion in a clinic.
“Sick people get abortions, and healthy people get abortions. Just like sick people get colonoscopies, and healthy people get colonoscopies,” Dr. Laursen, an OB-GYN who provides abortions at RUSH University Medical Center, said.
“It’s like we’ve siloed abortion so much that we think that it doesn’t have any other issues, but it’s just like any other procedure.”
Many of her patients are traveling from states with abortion bans, where chronic health conditions and maternal mortality are worse to begin with, she said. Seven of the 10 states that have declined to expand Medicaid to cover most poor adults also ban or restrict abortion.
Women in these states are less likely to have access to routine medical care to treat their chronic health issues, and providers said they are also less likely to seek obstetrical care back home, for fear that a physician might disclose their desire for an abortion.
Several pregnancy risk factors like eclampsia and previous C-section delivery are also higher in these states, particularly among Black women.
“It’s not that they just don’t have appropriate abortion care. They also don’t have the care they need for their regular medical problems,” said Dr. Allison Cowett, the medical director at Family Planning Associates, the clinic in Chicago where A. made an appointment.
Doctors thought A.’s ultrasound showed placenta accreta, one of the more common reasons an abortion would be done in a hospital rather than a clinic. It occurs when the placenta grows too deeply into the uterine wall, and it was most likely caused by scarring from the C-sections she had to deliver her two children, who are now 13 and 18.
A. didn’t know she had it until she arrived at her clinic appointment in Chicago and was told she couldn’t have the abortion there. “I thought my world was going to end,” she recalled. “I didn’t want to start over again.”
It is unlikely she would have qualified for an exception under Indiana’s abortion ban, and the next available hospital appointment in Chicago was a week away. She went to the zoo and waited around, hoping another patient would cancel, but nothing opened up.
“It just sucks that I have to go through all these hoops and run around because I can’t go in my own state,” she said.
Indiana, like most other states that have banned abortion, has pledged to better support health care for mothers — primarily by extending Medicaid coverage for up to one year postpartum. But doctors in Chicago said the emphasis on postpartum care offered a narrow window to address the underlying health issues many women in these states face.
“I know that a certain number of my patients — if they are unable to access abortion — are not going to survive their pregnancy,” said Dr. Jonah Fleisher, an OB-GYN who provides abortions at UI Health, a Chicago hospital.
Getting patients into hospitals
At the end of last year, Illinois abortion providers met with state officials to suggest a program to better serve the sickest abortion patients. In July, the state awarded them a $600,000 grant to start the Complex Abortion Regional Line for Access, or CARLA.
Two full-time nurses now coordinate referrals between Illinois abortion clinics and four Chicago-area hospitals. The nurses conduct a full medical intake over the phone; track down medical records; and figure out coverage when patients have insurance or connect them with the Chicago Abortion Fund when they don’t.
“We are here to help with the medical and logistical side of things, but we also navigate a lot of the emotional side,” said Caroline Nyheim, one of the two staff nurses. “Oftentimes patients have already been through a lot, and they are really frustrated and overwhelmed to be starting at square one again.”
A similar statewide hospital referral system was started in Massachusetts in 2003 and remains the only other program in the country of this kind.
Since the program started in August, CARLA has helped more than 100 patients, including A., secure an abortion at a Chicago hospital. About a third of patients traveled from out of state.
Medicaid covers the procedure cost for Illinois residents, but others are left to pay in full or seek help from an abortion fund. In Chicago, hospital procedures typically cost $3,000 to $6,000, and as much as $24,000 at one hospital.
The Chicago Abortion Fund has covered nearly all of the costs for CARLA patients so far, including the procedure, food, travel and lodging. But as more women with health issues seek abortion care in Illinois, spending will go up. Already, about 30 percent of the fund’s budget is going to help the 4 percent of patients whose abortions must be done in a hospital.
The city pledged $1 million to the fund this year, and in July, Gov. J.B. Pritzker of Illinois announced a series of initiatives around reproductive health care — including CARLA — totaling more than $23 million.
“When you’re in the midst of an emergency — and that’s what we’re in right now with abortion care — you’re simultaneously trying to deliver services and figure out how to hone it and make it better,” Mr. Pritzker said.
By the time of A.’s hospital appointment in mid-September, she was nearly 12 weeks pregnant. She was nervous, asking the anesthesiologist about whether she would feel anything. She didn’t want to.
She was out of the operating room in less than an hour and asked the doctor what to do if she had any complications. “God forbid I need to go to the emergency room in Indiana,” she said. “What do I say?”
The doctor advised her to say that she underwent a procedure for a miscarriage, before reassuring her that she would not end up in an emergency room.
A. twisted her belly-button ring back into place, grabbed her belongings and climbed into a wheelchair, where a nurse was waiting to take her outside. A friend would drive her back home.
“I think what scared me the most is that they were, like, you need it in the hospital because something could go wrong,” she said. “Imagine if I went to full term, and then something happened to me. Then it’s three babies left alone without a mom?”