What This Later-Abortion Story Tells Us About a Post-Roe Future
In October of 2021, Kristyn Smith checked herself out of the hospital in Charleston, W.Va., where she had been denied an abortion. Bleeding and in pain, Smith drove for six hours with her fiancé to Washington, D.C., to have the procedure performed there. On the day of her first appointment at the Dupont Clinic, she was 27 weeks pregnant. “They were the sweetest, most compassionate people that I had ever met,” she said of the clinic staff, who made her feel safe and supported. The seven weeks leading up to her arrival there, however, had been a “nightmare.”
Less than two months after her abortion, Smith contacted me after finding my podcast, ACCESS. She sent an e-mail with the subject line “Abortion at 27 weeks” that detailed her story of agonizing delays and denials of care. In many parts of the country—particularly in the South and the Midwest—getting an abortion at any stage of pregnancy is difficult because of the dwindling number of abortion providers, the onerous legal restrictions, and other financial and logistical barriers. But getting an abortion later in pregnancy, particularly in the third trimester, is difficult everywhere. Twenty-two states have bans in effect that prohibit abortion starting between 20 and 24 weeks’ gestation, and 20 states impose a ban at viability, generally recognized as 24 weeks. When exceptions to these bans exist, they are often narrowly applied, and in the handful of states where third-trimester abortion is legal, there are few providers.
According to a 2014 Guttmacher Institute report, while 72 percent of abortion clinics offer care up to 12 weeks, only 25 percent offer care up to 20 weeks, and just 10 percent offer it through 24 weeks. Following the 2009 murder of Dr. George Tiller—who was relentlessly targeted by anti-abortion extremists for more than a decade because he provided abortions in the third trimester—very few doctors are willing to openly provide this care. A small number of clinics provide abortions at 26 weeks and beyond; all are independent, meaning they are not affiliated with Planned Parenthood and therefore have less public and institutional support. Hospitals are more likely to provide abortion care later in pregnancy; however, hospitals perform only about 4 percent of all abortions in the United States, and many have policies that limit abortion care.
Any day now, the Supreme Court is expected to issue a ruling that could overturn Roe v. Wade or gut it beyond meaning. In that event, 26 states are poised to ban abortion to the fullest extent possible. Many things have changed profoundly since the pre-Roe days; perhaps most significant, illegal abortions can be medically safe thanks to the advent of medication abortion. However, anti-abortion policies still endanger lives, as in Smith’s case, by delaying or denying care in life-threatening situations. What’s more, research shows that most people who need abortions later in pregnancy experienced logistical delays in accessing care at an earlier point in the pregnancy. These delays will only compound if abortion is banned in roughly half the country, because thousands of patients will be forced to travel across state lines to the few remaining clinics. The number of people seeking later abortions is undoubtedly about to increase, and our medical system is unprepared to care for them.
Smith’s pregnancy was a wanted one. She knows that stories like hers—involving fatal fetal diagnoses and health risks—are often presented as exceptional and used to undercut the needs of people whose reasons for seeking an abortion may be less sympathetic to some. Smith is unequivocal that later abortion patients deserve care regardless of the reason. “Abortion is health care; it is needed,” she said. “It saves lives, even if not physically like mine.”
Smith discovered she was pregnant just over six months after giving birth to her third child. The pregnancy was a surprise, but it quickly became a happy one. Smith and her fiancé picked a name: Kase. “We were ecstatic,” she told me.
In the early ultrasounds, Smith said, “everything was perfect and healthy, just as in my other three pregnancies.” But during her 20-week anatomy scan, things took a turn. Kase’s kidneys and bladder were dilated, and very little amniotic fluid surrounded him. Without enough amniotic fluid, the lungs cannot develop properly. The fluid also cushions the fetus and allows it to move, so low levels can result in restrictions on growth and other musculoskeletal complications.
Smith’s ob-gyn referred her to a team of maternal-fetal medicine (MFM) specialists in Cincinnati, a three-and-a-half-hour drive from her home. Smith lives near Charleston, which is one of West Virginia’s largest cities but has a population of less than 50,000. Nearly all of the MFM specialists in the US—particularly those practicing cutting-edge techniques like fetal surgery—reside in urban areas, which poses a significant barrier for those with high-risk pregnancies in rural or smaller metropolitan areas, who may not have the means to travel. According to a 2020 report from the March of Dimes, 2.2 million women in the US live in maternity care deserts.
Smith made two trips to Cincinnati, initially hopeful that she might be able to continue the pregnancy with the help of fetal surgery. “Looking back,” she says, “I was naive.” Only after speaking with the specialists did Smith realize just how serious the situation was. Kase’s urinary tract appeared completely blocked, and as a result his lungs were severely underdeveloped and his heart looked small. Even if surgery successfully corrected the obstruction, it would be a difficult road ahead.
“He would have been in the NICU up in Cincinnati for at least six months,” Smith said. “And that would have been with 10 to 20 surgeries in his first year of life, [and] monthly doctor appointments back up in Cincinnati. And to put my three kids’ lives on hold for that? My relationship with my fiancé, my whole life would have been turned upside down. And we’re not wealthy. We don’t have money to do those things.”
Still, they tried. Smith underwent tests and procedures in preparation for the surgery, but there were complications during one of the procedures. The doctors told Smith she wouldn’t be able to have the surgery the following week as planned. By this time, she was 23 weeks pregnant. They counseled her on her options, including terminating the pregnancy or allowing “nature [to] take its course,” meaning that she could go home and wait to have a stillbirth.