For Shyanne McCoy, 23, that meant the closest hospital with an obstetrician on staff when she was pregnant was a 45-mile drive away over a mountain pass.

When McCoy developed symptoms of preeclampsia last January, she felt she had the best chance of getting the care she needed at a larger hospital in Boise, Idaho, two hours away. She spent the final week of her pregnancy there, too far from home to risk leaving, before giving birth to her daughter.

Six months later, she said it seems clear to her that the health care needs of rural young women like her are largely ignored.

For McCoy and others, figuring out how to obtain adequate care to safely have a baby in Baker City has quickly eclipsed concerns about another medical service lacking in the area: abortion. But in Oregon and elsewhere in the country, progressive lawmakers’ attempts to expand abortion access sometimes clash with rural constituencies.

Oregon is considered one of the most protective states in the country when it comes to abortion. There are no legal limits on when someone can receive an abortion in the state, and the service is covered by its Medicaid system. Still, efforts to expand access in the rural, largely conservative areas that cover most of the state have encountered resistance and incredulity.

It’s a divide that has played out in elections in such states as Nevada, where voters passed a ballot measure in November that seeks to codify abortion protections in the state constitution. Residents in several rural counties opposed the measure.

In Oregon, during the months just before the Baker City closure was announced, Democratic state lawmakers were focused on a proposed pilot program that would launch two mobile reproductive health care clinics in rural areas. The bill specified that the van-based clinics would include abortion services.

State Rep. Christine Goodwin, a Republican from a southwestern Oregon district, called the proposal the “latest example” of urban legislators telling rural leaders what their communities need.

The mobile health clinic pilot was eventually removed from the bill that was under discussion. That means no new abortion options in Oregon’s Baker County — and no new state-funded maternity care either.

“I think if you expanded rural access in this community to abortions before you extended access to maternal health care, you would have an uprising on your hands,” said Paige Witham, 27, a member of the Baker County health care steering committee and the mother of two children, including an infant born in October.

A study published in nearly 5,000 acute care hospitals found that by 2022, 52% of rural hospitals lacked obstetrics care after more than a decade of unit closures. The health implications of those closures for young women, the population most likely to need pregnancy care, and their babies can be significant. that added distance between a patient and obstetric care increases the likelihood the baby will be admitted to a neonatal intensive care unit, or NICU.

Witham said that while she does not support abortion, she believes the government should not “legislate it away completely.” She said that unless the government provides far more support for young families, like free child care and better mental health care, abortion should remain legal.

Conversations with a liberal school board member, a moderate owner of a timber company, members of Baker City’s Republican Party chapter, a local doula, several pregnant women, and the director of the Baker County Health Department — many of whom were not rigidly opposed to abortion — all turned up the same answer: No mobile clinics offering abortions here, please.

Kelle Osborn, a nurse supervisor for the Baker County Health Department, loved the idea of a mobile clinic that would provide education and birth control services to people in outlying areas. She was less thrilled about including abortion services in a clinic on wheels.

“It’s not something that should just be handed out from a mobile van,” she said of abortion services. She said people in her conservative rural county would probably avoid using the clinics for anything if they were understood to provide abortion services.

Both Osborn and Meghan Chancey, the health department’s director, said they would rank many health care priorities higher, including the need for a general surgeon, an ICU, and a dialysis clinic.

Nationally, reproductive health care services of all types tend to be limited for people in rural areas, even within states that protect abortion access. More than two-thirds of people in “maternity care deserts” — all of which are in rural counties — must drive more than a half-hour to get obstetric care, according to a . For people in the Southern states where lawmakers installed abortion bans, abortion care can be up to 700 miles away, according to a .

Nathan Defrees grew up in Baker City and has practiced medicine here since 2017. He works for a family medicine clinic. If a patient asks about abortion, he provides information about where and how one can be obtained, but he doesn’t offer abortions himself.

“There’s not a lot of anonymity in small towns for physicians who provide that care,” he said. “Many of us aren’t willing to sacrifice the rest of our career for that.”

He also pointed to the small number of patients requesting the service locally. Just six people living in Baker County had an abortion in 2023, according to data from the Oregon Department of Public Health. Meanwhile, 125 residents had a baby that year.

A doctor with obstetric training living in another rural part of the state has chosen to quietly provide early-stage abortions when asked. The doctor, concerned for their family’s safety in the small, conservative town where they live, asked not to be identified.

The idea that better access to abortion is not needed in rural areas seems naive, the doctor said. People most in need of abortion often don’t have access to any medical service not already available in town, the doctor pointed out. The first patient the doctor provided an abortion for at the clinic was a meth user with no resources to travel or to manage an at-home medication abortion.

“It seemed entirely inappropriate for me to turn her away for care I had the training and the tools to do,” the doctor said.

Defrees said it has been easier for Baker County residents to get an abortion since the U.S. Supreme Court overturned Roe v. Wade.

A new Planned Parenthood clinic in Ontario, Oregon, 70 miles away in neighboring Malheur County, was built primarily to provide services to people from the Boise metro area, but it also created an option for many living in rural eastern Oregon.

Idaho is one of the 16 states with near-total bans on abortion. Like many states with bans, Idaho has struggled to maintain its already small fleet of fetal medicine doctors. The loss of regional expertise touches Baker City, too, Defrees said.

For example, he said, the treatment plan for women who have a desired pregnancy but need a termination for medical reasons is now far less clear. “It used to be those folks could go to Boise,” he said. “Now they can’t. That does put us in a bind.”

Portland is the next closest option for that type of care, and that means a 300-mile drive along a set of highways that can be treacherous in winter.

“It’s a lot scarier to be pregnant now in Baker City than it ever has been,” Defrees said.

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He blames his addiction. He started using in middle school, and by the time he was an adult he was addicted to meth and heroin. At various points, he’s done time alongside his mom, his dad, his sister, and his younger brother.

“That’s all I’ve known my whole life,” said Clark, 31, in December.

Clark was at the jail to pick up his sister, who had just been released. The siblings think this time will be different. They are both sober. Shantel Clark, 33, finished earning her high school diploma during her four-month stay at the jail. They have a place to live where no one is using drugs.

And they have Cheryl Swapp, the county sheriff’s new community health worker, on their side.

“She saved my life probably, for sure,” Garrett Clark said.

Swapp meets with every person booked into the county jail soon after they arrive and helps them create a plan for the day they get out.

She makes sure everyone has a state ID card, a birth certificate, and a Social Security card so they can qualify for government benefits, apply to jobs, and get to treatment and probation appointments. She helps nearly everyone enroll in Medicaid and apply for housing benefits and food stamps. If they need medication to stay off drugs, she lines that up. If they need a place to stay, she finds them a bed.

Then Swapp coordinates with the jail captain to have people released directly to the treatment facility. Nobody leaves the jail without a ride and a drawstring backpack filled with items like toothpaste, a blanket, and a personalized list of job openings.

“A missing puzzle piece,” Sgt. Gretchen Nunley, who runs educational and addiction recovery programming for the jail, called Swapp.

Swapp also assesses the addiction history of everyone held by the county. More than half arrive at the jail addicted to something.

Nationally, booked into local jails struggle with a substance use disorder — at least six times the rate of the general population, according to the federal Substance Abuse and Mental Health Services Administration. The incidence of mental illness in jails is more than twice the rate in the general population, federal data shows. At least 4.9 million people are arrested and jailed every year, according to an by the Prison Policy Initiative, a nonprofit organization that documents the harm of mass incarceration. Of those incarcerated, 25% are booked two or more times, the analysis found. And among those arrested twice, more than half had a substance use disorder and a quarter had a mental illness.

“We don’t lock people up for being diabetic or epileptic,” said David Mahoney, a retired sheriff in Dane County, Wisconsin, who served as president of the in 2020-21. “The question every community needs to ask is: ‘Are we doing our responsibility to each other for locking people up for a diagnosed medical condition?’”

The idea that county sheriffs might owe it to society to offer medical and mental health treatment to people in their jails is part of a broader shift in thinking among law enforcement officials that Mahoney said he has observed during the past decade.

“Don’t we have a moral and ethical responsibility as community members to address the reasons people are coming into the criminal justice system?” asked Mahoney, who has 41 years of experience in law enforcement.

Swapp previously worked as a teacher’s aide for those she calls the “behavior kids” — children who had trouble self-regulating in class. She feels her work at the jail is a way to change things for the parents of those kids. And it appears to be working.

Since the Sanpete County Sheriff’s Office hired Swapp last year, recidivism has dropped sharply. In the 18 months before she began her work, 599 of the people booked into Sanpete County Jail had been there before. In the 18 months after she started, that number dropped to 237.

In most places, people are released from county jails with no health care coverage, no job, nowhere to live, and no plan to stay off drugs or treat their mental illness. that people newly released from incarceration face a risk of overdose that is 10 times as high as that of the general public.

Sanpete wasn’t any different.

“For seven to eight years of me being here, we’d just release people and cross our fingers,” said Jared Hill, the clinical director for Sanpete County and a counselor at the jail.

Nunley, the programming sergeant, remembers watching people released from jail walk the mile to town with nothing but the clothes they’d worn on the day they were arrested — it was known as the “walk of shame.” Swapp hates that phrase. She said no one has made the trip on foot since she started in July 2022.

Swapp’s work was initially funded by a grant from the U.S. Health Resources and Services Administration, but it has proved so popular that commissioners in Sanpete County voted to use a portion of its to cover the position in the future.

Swapp doesn’t have formal medical or social work training. She is certified by the state of Utah as a community health worker, a job that has become more common nationwide. There were about 67,000 people working as community health workers in 2022, according to the .

Evidence is mounting that the model of training people to help their neighbors connect to government and health care services is sound, said Aditi Vasan, a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania who has on the relatively new role.

The day before Swapp coordinated Shantel Clark’s release, she sat with Robert Draper, a man in his 50s with long white hair and bright-blue eyes. Draper has been in and out of jail for decades. He was sober for a year and had been taking care of his ill mother. She kept getting worse. Then his daughter and her child came to help. It was all a little too much.

“I thought, if I can just go and get high, I can deal with this shit,” said Draper. “But after you’ve been using for 40 years, it’s kinda easy to slip back in.”

He didn’t blame his probation officer for throwing him back in jail when he tested positive for drugs, he said. But he thinks jail time is an overreaction to a relapse. Draper sent a note to Swapp through the jail staff asking to see her. He was hoping she could help him get out so he could be with his mom, who had just been sent to hospice. He had missed his father’s death years ago because he was in jail at the time.

Swapp listened to Draper’s story without interruptions or questions. Then she asked if she could run through her list with him so she would know what he needed.

“Do you have your Social Security card?”

“My card?” Draper shrugged. “I know my number.”

“Your birth certificate, you have it?”

“Yeah, I don’t know where it is.”

“Driver’s license?”

“No.”

“Was it revoked?”

“A long, long time ago,” Draper said. “DUI from 22 years ago. Paid for and everything.”

“Are you interested in getting it back?”

“Yeah!”

Swapp has some version of this conversation with every person she meets in the jail. She also runs through their history of addiction and asks them what they most need to get back on their feet.

She told Draper she would try to get him into intensive outpatient therapy. That would involve four to five classes a week and a lot of driving. He’d need his license back. She didn’t make promises but said she would talk to his probation officer and the judge. He sighed and thanked her.

“I’m your biggest fan here,” Swapp said. “I want you to succeed. I want you to be with your mom, too.”

The federal grant that funded the launch of Sanpete’s community health worker program is held by the regional health care services organization Intermountain Health. Intermountain took the idea to the county and has provided Swapp with support and training. Intermountain staff also administer the $1 million, three-year grant, which includes efforts to increase addiction recovery services in the area.

A similarly funded program in Kentucky called First Day Forward took the community health worker model a step further, using “peer support specialists” — people who have experienced the issues they are trying to help others navigate. Spokespeople from HRSA pointed to four programs, including the ones in Utah and Kentucky, that are using their grant money for people facing or serving time in local jails.

Back in Utah, Sanpete’s new jail captain, Jeff Nielsen, said people in small-town law enforcement weren’t so far removed from those serving time.

“We know these people,” Nielsen said. He has known Robert Draper since middle school. “They are friends, neighbors, sometimes family. We’d rather help than lock them up and throw away the key. We’d rather help give them a good life.”

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“What price did they quote you?” Bell asked a woman from New Jersey who had called the organization’s hotline seeking money to pay for an abortion. Her appointment was the next day.

“They quoted me $500,” said the woman, who was five weeks pregnant when she spoke to Bell in November. She gave permission for a journalist to listen to the call on the condition that she not be named.

“We can definitely help,” Bell told her. “We can cover the cost of the procedure. You just tell them you have a pledge from the NAF.”

Bell is one of a growing network of workers who help people seeking abortions understand what’s legal, where they can travel for care, and how to get there.

These “navigators” can often recite from memory the names and locations of clinics throughout their region that offer abortion services at a given point in a pregnancy. Often, they can then name the hotel closest to the clinic. And some are so familiar with the most common airports for connecting flights that they can help patients find their next departure gate in real time.

State abortion laws have always varied, so helping people access legal abortion services isn’t new, but the amount of travel needed to get care has risen sharply.

In the first six months of 2023, nearly 1 in 5 abortion patients traveled out of state to get care, compared with 1 in 10 in 2020, by the Guttmacher Institute, a national nonprofit that supports abortion rights. That increase in travel, even for early-pregnancy abortions, has sparked a corresponding rise in the need for case managers like Bell.

Most callers are like the woman from New Jersey — people in the early stages of a pregnancy who can’t afford the $500 cost of a medication abortion. But with elective almost entirely in 14 states and after six weeks in two more, the logistics of ending a pregnancy at any stage have become more complicated.

“People are being forced later into pregnancies to access care” because of the difficulty of arranging travel over long distances and the chilling effect of the bans, said Brittany Fonteno, president of the NAF, a nonprofit professional organization of clinics that provide abortions. “It increases the cost of care and has a devastating impact on people.”

After hanging up with the woman from New Jersey, Bell told a woman from Georgia that she likely wouldn’t need to pay the $4,800 bill for her 24-week abortion. Half the money would come from the National Abortion Federation and Bell would contact local organizations that have their own abortion access funds to find the rest. Once the money was sorted, the woman told Bell she couldn’t decide whether she should drive more than 14 hours to Washington, D.C., for her care or buy a plane ticket. Her appointment was the following week.

“I was looking at flights, but most of them won’t be there at the time that I need to be there,” she told Bell, a former librarian who talks to as many as 40 callers a day. The Georgia woman said she had $1,200 saved for the trip. Because of the length of a second-trimester abortion procedure, she would likely have to stay in Washington for three nights.

“Sometimes we can help with travel,” Bell told the Georgia caller. “Book the flight and hotel to see if the $1,200 covers those things, also meals and ride-shares from airport to hotel. Factoring in all of those expenses, if you feel like $1,200 doesn’t cover that, reach back out to me immediately.”

Since July 2022, NAF case managers like Bell have helped patients pay for nearly three times the number of hotel rooms and plane, train, and bus tickets each month as they did before the Supreme Court overturned Roe v. Wade, which had recognized a constitutional right to abortion. The most requests for financial assistance have come from people in Texas, Georgia, Florida, and Alabama — populous states with strict abortion laws. Calls are also longer and more involved. The nonprofit now spends $200,000 a month (up from $30,000 a month before Texas in 2021) and is still not meeting the need, Fonteno said.

In 2020, Fonteno’s organization employed about 30 full-time hotline operators. That number rose when Texas passed its six-week ban. And since the Dobbs decision overturning Roe, the line has employed 45 to 55 people, said Melissa Fowler, the NAF’s chief program officer.

Other reproductive health organizations — at the local, regional, and national levels — have also added staff like Bell. Planned Parenthood affiliates, including some in states with full bans, now employ 98 people known as patient navigators. Most were hired after Dobbs, said Danika Severino Wynn, vice president of abortion access for Planned Parenthood Federation of America. She estimates 127,000 people have relied on these navigators since July 2021.

Planned Parenthood Columbia Willamette in Portland, Oregon, has hired three abortion patient navigators since Roe was overturned, according to spokesperson Sam West. Abortion is legal in Oregon, with no restrictions, but that doesn’t mean everyone has equal access to services. One of the new navigators speaks Spanish and focuses on the rural parts of the state, where services are sparse.

The clinic declined a request for a journalist to listen in on calls with its navigators, citing patient privacy. The two other navigators focus on helping callers who are from out of state (usually Idaho), are younger than 15, or are in their second trimester.

Lawyers contacted for this story who are familiar with current state laws said patient navigators are unlikely to be at legal risk for their work helping people connect with abortion services, though it could matter which state they are sitting in when they offer help. For example, an Idaho law stating that adults in Idaho are not allowed to “recruit” minors to get an abortion could apply to navigators if they answered the phone in Idaho. That law, along with many others in states with bans, is being challenged in court.

Back at her desk in Georgia, Bell took a call from a 20-year-old woman in North Carolina named Deshelle, who was seeking financial support for a second-trimester abortion. Deshelle talked with ºÚÁϳԹÏÍø News a few days later, speaking on the condition that only her middle name be used, to protect her privacy.

On the day Deshelle became pregnant, it was legal to get an abortion in North Carolina at up to 20 weeks of pregnancy. About six weeks later, when she discovered she was pregnant, she went to a nearby clinic to have a medication abortion. She went to the first appointment to fill out paperwork. She was required by state law to wait 72 hours before returning to get the abortion pills. She was also given an ultrasound she didn’t want. The image of the embryo rattled her and she skipped the second appointment.

By the time Deshelle decided again to go ahead with an abortion, she was nearly 15 weeks pregnant and the North Carolina law had changed. By July 1, nearly all abortions after 12 weeks were banned. She would have to go out of state.

With the help of NAF navigators, Deshelle made an appointment at a clinic in Virginia, where a 15-week abortion is legal. Her mother drove but did not support Deshelle’s decision to end the pregnancy. Then there were protesters. By the time Deshelle got inside, she was crying. She met with a provider but decided once again not to go through with the abortion.

None of that came up on her call with Bell in November. By that time, Deshelle was 26 weeks pregnant. It was her second time calling the hotline and her third time trying to get an abortion. She just wanted to know if she could still get financial assistance. The cost of her care had escalated from about $500 when she could have gotten a medication abortion to $6,500 for a multiday abortion procedure.

Bell took her cue from Deshelle and stayed focused on logistics. She approved funding to cover half the cost of the procedure and secured a donation to cover the rest. She confirmed that Deshelle had a place to stay and the required companion to go to the clinic with her each day. Then they hung up. The rest of the journey was Deshelle’s alone.

“This isn’t what I want, but I think it’s the best choice for me,” Deshelle said from just outside the waiting room on the first day of the procedure. She read aloud from a pamphlet about the medications she’d be given and the timing of it all. Then her name was called.

A week later, after it was all over, she still felt she’d done the right thing.

“You literally have to be really strong to abort your baby and be OK,” she said she’d tell anyone else in her situation, “and you also have to be really strong to be a single mom.”

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