ATLANTA — At a routine ultrasound when she was five months pregnant, Hevan Lunsford began to panic when the technician took longer than normal, then told her she would need to see a specialist.
Lunsford, a nurse in Alabama, knew it was serious and begged for an appointment the next day.
That’s when the doctor gave her and her husband the heart-wrenching news: The baby boy they decided to name Sebastian was severely underdeveloped and had only half a heart. If he survived, he would need care to ease his pain and several surgeries. He may not live long.
Lunsford, devastated, asked the doctor about ending the pregnancy.
“I felt the only way to guarantee that he would not have any suffering was to go through with the abortion,” she said of that painful decision nearly three years ago.
But the doctor said Alabama law prohibits abortions after five months. He handed Lunsford a piece of paper with information for a clinic in Atlanta, a roughly 180-mile drive east.
Lunsford is one of thousands of women in the U.S. who have crossed state lines for an abortion in recent years as states have passed ever stricter laws and as the number of clinics has declined.
Although abortion opponents say the laws are intended to reduce abortions and not send people to other states, at least 276,000 women terminated their pregnancies outside their home state between 2012 and 2017, according to an Associated Press analysis of data collected from state reports and the U.S. Centers for Disease Control and Prevention.
In New Mexico, the number of women from out of state who had abortions more than doubled in that period, while Missouri women represented nearly half the abortions performed in neighboring Kansas.
“The procedure itself was probably the least traumatic part of it,” Lunsford said. “If it would have been at my hospital, there would have been a feeling like what I was doing was OK and a reasonable choice.”
While abortions across the U.S. are down, the share of women who had abortions out of state rose slightly, by half a percentage point, and certain states had notable increases over the five-year period, according to AP’s analysis.
In pockets of the Midwest, South and Mountain West, the number of women terminating a pregnancy in another state rose considerably, particularly where a lack of clinics means the closest provider is in another state or where less restrictive policies in a neighboring state make it easier and quicker to terminate a pregnancy there.
“In many places, the right to abortion exists on paper, but the ability to access it is almost impossible,” said Amy Hagstrom Miller, CEO of Whole Women’s Health, which operates seven abortion clinics in Maryland, Indiana, Texas, Virginia and Minnesota. “We see people’s access to care depend on their ZIP code.”
Nationwide, women who traveled from another state received at least 44,860 abortions in 2017, the most recent year available, according to the AP analysis of data from 41 states.
That’s about 10% of all reported procedures that year, but counts from nine states, including highly populated California and Florida, and the District of Columbia were not included either because they were not collected or reported across the full five years.
Thirteen states saw a rise in the number of out-of-state women having abortions between 2012 and 2017.
New Mexico’s share of abortions performed on women from out of state more than doubled from 11% to roughly 25%. One likely reason is that a clinic in Albuquerque is one of only a few independent facilities in the country that perform abortions close to the third trimester without conditions.
Georgia’s share of abortions performed on out-of-state women rose from 11.5% to 15%. While Georgia has passed restrictive laws, experts and advocates still view it as more accessible than some neighboring states.
In Illinois, the percentage of abortions performed on non-residents more than doubled to 16.5% of all reported state abortions in 2017. That is being driven in large part by women from Missouri, one of six states with only a single abortion provider.
Even that provider, Planned Parenthood’s Reproductive Health Services clinic in St. Louis, has been under threat of closing after the state health department refused to renew its license.
Missouri lawmakers also passed a law this year that would ban almost all abortions past eight weeks of a pregnancy. The law was to go into effect Aug. 28, but a federal judge temporarily blocked it as a legal challenge plays out in court.
With access to abortion services narrowing in Missouri, the Hope Clinic in Granite City has seen a 30% increase in patients this year and has added two doctors, deputy director Alison Dreith said.
About 55% of Hope Clinic’s patients come from Missouri, and it also sees women from Indiana, Kentucky and Ohio. All those states have mandatory waiting periods to receive an abortion, a requirement Illinois does not have.
Dreith called it a scary time for women in states with highly restrictive laws and few clinics.
“The landscape that we’re seeing today did not happen overnight, and it was not by accident,” she said.
And Illinois isn’t the only place Missouri women are heading for abortions.
In 2017, Missouri women received 47% of all abortions performed in Kansas. That is in large part because the only access to the procedure throughout western Missouri, particularly the greater Kansas City area, is across the state line in Overland Park, Kansas.
Between 2011 and May 31 of this year, 33 states passed 480 laws restricting abortion, according to the Guttmacher Institute, a research organization that supports abortion rights.
In 2019 alone, lawmakers approved 58 restrictions primarily in the Midwest, Plains and South — almost half of which would ban all, most or some abortions, the group said.
The most high-profile laws, which face legal challenges that could eventually test the U.S. Supreme Court’s Roe v. Wade decision, would ban abortion after a fetal heartbeat can be detected — as early as six weeks.
Advocates say that if the Supreme Court upholds the latest restrictions, it will become more common for women to seek an abortion in another state.
“The intent of these lawmakers is to completely outlaw abortion and force people not to have abortions. But in reality, it pushes people farther and wider to access the care they want and need,” said Quita Tinsley, deputy director of Access Reproductive Care Southeast.
ARC Southeast is part of the National Network of Abortion Funds, a collective of 70 abortion support groups for women in six Southeast states. Some provide money to women to pay for abortions, while others also help with transportation, lodging and child care.
A third of women calling the group’s hotline for help end up traveling out of state for abortions, Tinsley said. Many choose Georgia because it’s convenient to get to and considered slightly less restrictive than some other states in the South.
In Georgia, which has a mandatory waiting period, a woman is not required to come to a clinic twice, like they are in Tennessee. But if Georgia’s new fetal heartbeat law survives a court challenge, it would have one of the earliest state-imposed abortion bans.
That would force many women to go even farther from where they live to terminate their pregnancies.
Abortion opponents say the intent of laws limiting the procedure is not to push women to another state but to build more time for them to consider their options and reduce the overall number of abortions.
“I have been insistent in telling my pro-life colleagues that’s all well and good if the last abortion clinic shuts down, but it’s no victory if women end up driving 10 minutes across the river to Granite City or to Fairview Heights,” said Sam Lee, director of Campaign Life Missouri and a longtime anti-abortion lobbyist.
Anti-abortion activists also hope a broader cultural shift eventually makes these issues disappear.
“We are seeing this trend toward life and a realization of what science tells us about when life begins,” said Cole Muzio, executive director of the Family Policy Alliance of Georgia who advocated successfully for new abortion limits there. “Just because something is legal does not mean that it is good.”
Before the recent wave of legislation focused on limiting when an abortion can be performed, opponents largely worked to regulate clinics. Critics say those regulations contributed to more clinics closing in recent years, reducing access to abortion in parts of the country and pushing women farther for care.
Nationwide, 168 independent abortion clinics have closed since 2012, and just a handful opened over that time, according to the Abortion Care Network, a clinic advocacy group.
Some resulted from providers retiring and an overall decline in unplanned pregnancies, but advocates say many shut down because of restrictive laws.
“It’s not about safety of patients,” said Nikki Madsen, executive director of the Abortion Care Network. “It’s about closing clinics.”
For Lunsford, it took two years before she could begin managing the grief of losing her son, compounded by the hurdles she faced to carry out that painful decision — the drive to Atlanta, staying in a hotel and going to a clinic with doctors she didn’t know.
Lunsford, now 31, said she thinks about how she couldn’t hold her baby, an intimate goodbye that might have been possible if she had the abortion at a hospital. Before she left Atlanta, she asked the clinic’s staff to use the inkpad and paper she brought so she could keep her son’s footprints and handprints.
“Most of the laws I navigated, there was no reason for them,” she said. “None of them prevented my abortion. It just made it where I had to travel out of state.”
Associated Press Data Editor Meghan Hoyer contributed to this report. Also contributing were AP writers John D. Hanna in Topeka, Kansas, and Susan Montoya Bryan in Albuquerque, New Mexico.