On Monday, Iowa became the fourth state where abortion is banned at roughly six weeks of pregnancy. This is in addition to the 14 states that ban abortion entirely, and four more that have made their laws more restrictive since the overturn of Roe v. Wade in 2022.

That’s to say nothing of the abortion restrictions that were already in place in many states prior to the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, most of which remain in place today.

Hardest hit is the Southeast, where abortion was already largely inaccessible prior to Dobbs, especially beyond the first trimester. Now, abortion is banned entirely or at six weeks across almost the entire region. And since Florida’s six-week ban went into effect on May 1—after an earlier 15-week ban had already decimated access—the large wave of traveling abortion seekers from the South became a tsunami.

Many of these patients are now traveling up the East Coast to clinics in Virginia, Washington, D.C., and New York City. Others—particularly those from Texas and Oklahoma—are traveling west to states like Colorado and New Mexico.

But many are also traveling to the Midwest, a region with a complex patchwork of abortion laws and longstanding access challenges for its own residents.

Abortion providers and funders in the Midwest say they’re prepared to support Iowans who need to travel out of state, along with all the out-of-state patients they care for already. But in a landscape where abortion seekers are increasingly faced with the choice of either traveling farther and farther from home, or obtaining abortion pills online, money is what enables abortion access. And as the post-Dobbs donation bump disappears, Midwestern abortion funds and clinics told Rewire News Group the biggest challenge they face is making sure the money doesn’t dry up.

A confusing patchwork of laws

When it comes to the legal status of abortion across the Midwest, it’s complicated.

The region is home to several states with total abortion bans, including Indiana, Missouri, and North and South Dakota. But it is also home to Minnesota and Michigan, two states with some protections for abortion rights, and Illinois, another protective state that is a major destination for traveling abortion seekers. According to the Society of Family Planning’s latest We Count report, analyzing data between April 2022 and December 2023, Illinois saw the single largest increase in its abortion rate of any state.

In Wisconsin, abortion was swiftly outlawed after the Dobbs decision thanks to a pre-Roe criminal abortion ban. However, a September 2023 court decision restored the pre-Dobbs status quo and abortion care resumed—though that status quo is still restrictive.

Ohio’s constitution, too, now protects abortion rights after a successful ballot campaign in 2023. But the constitutional amendment did not automatically repeal the state’s many abortion restrictions, and abortion is still only available until 22 weeks.

In Nebraska, abortion has been banned after 12 weeks since May 2023. In nearby Kansas—thanks to voters’ defeat of an anti-abortion ballot measure—it remains legal until 22 weeks. But in May, abortion access in Kansas suffered a blow when Wichita’s Trust Women clinic, one of only six in the state, unexpectedly shut down following the board’s removal of the entire senior leadership team. Trust Women confirmed to Rewire News Group that it is on track to reopen within the next week.

A host of Kansas abortion restrictions were recently defeated at the state supreme court, but others remain in place.

Iowa faces an already dire situation

Lyz Lenz, a board member of the Iowa Abortion Access Fund (IAAF), pointed out that Iowans can still obtain abortion pills by telemedicine from providers in legal states or via other online sources. And IAAF is prepared to help people travel out of state as needed.

“We’re the second-oldest abortion fund in the nation,” Lenz said. “We are not going anywhere.”

IAAF has already seen a 27 percent increase in requests for funding since 2021 and a 7 percent increase compared to last year in just the first half of 2024, said Lenz, who added that many people were already traveling out of state due to Iowa’s restrictive abortion laws.

But abortion bans affect all reproductive and sexual health care. Across the country, OB-GYNs have fled abortion ban states, and medical residents have increasingly declined to train in them. In Iowa, the situation was already dire: There are fewer OB-GYN specialists per capita there than in any other state in the nation.

A 2023 study by March of Dimes found that one-third of Iowa counties are maternity care deserts. More than one-third of the state’s population lives in rural areas, but as of January, 61 percent of its rural hospitals don’t offer labor and delivery services. Earlier this year, a major Des Moines hospital had to shut down its gynecologic oncology program because it couldn’t find a doctor to run it.

And should the state’s six-week ban cause more doctors to flee, the burden will fall most heavily on the state’s most marginalized populations, said Ashley Garrin, vice president of the Iowa Black Doula Collective.

It’s challenging already for Black Iowans—who make up about 4 percent of the state’s population—to receive high-quality, culturally competent care, Garrin said.

“I’m in Des Moines, the capital city, which is the most diverse in the state,” she said. “And we have only two Black female OBs that exist throughout the different medical systems here.”

“Across the nation, Black women are three to four times more likely to die in childbirth compared to their white counterparts,” Garrin added. “In Iowa, it is seven times more.”

She also noted that the cesarean section rate among Black women is “extremely” high in Iowa, and expressed concern that recent advances in reducing the infant mortality rate could be reversed due to the ban.

As of now, two abortion clinics remain open in Iowa: a Planned Parenthood affiliate in Ames and the Emma Goldman Clinic in Iowa City. But pregnancy dating is confusing, and Garrin pointed out that many people who could potentially access legal abortion care in Iowa may not have the health literacy to get there.

“I have a daughter who’s 13, and if I think about the sex education that she’s been exposed to at school, it doesn’t cover those kinds of things,” Garrin said.

Providing care to an influx of out-of-state patients

Most Iowans who need to travel out of state will likely go east to Illinois or north to Minnesota, with some possibly traveling to Nebraska or farther afield where they have personal connections.

According to Dr. Iman Alsaden, medical director at Planned Parenthood Great Plains (PPGP), Midwestern abortion providers are adept at caring for traveling patients. They’ve been doing it since long before Dobbs.

For example, PPGP operates clinics in Arkansas, Kansas, Missouri, and Oklahoma. But patients from Missouri had long traveled to Kansas for abortion care due to the restrictive environment in their home state.

Historically, abortion restrictions that send a flood of patients traveling from one state to another tend to displace the residents of that “destination” state.

“When SB 8 went into effect in Texas [in 2021], everyone from Texas went to Oklahoma City and Tulsa,” Alsaden said. “And then all of a sudden in Kansas City, we were seeing people from Oklahoma, even though abortion was legal in Oklahoma at that time.”

But three Illinois abortion providers told Rewire News Group that so far, this hasn’t been the case there. This is, in part, because several new clinics have opened in the state. One of those is CHOICES, a longtime Memphis, Tennessee abortion provider that started working to open a clinic in the Southern Illinois college town of Carbondale back in 2021. CHOICES opened its Carbondale location in October 2022, and its Memphis health center remains open as well, providing a range of reproductive and sexual health services even though it can no longer offer abortion care.

“2023 was our first full year of seeing patients, and we saw right about 3,500 patients in Carbondale,” CHOICES President and CEO Jennifer Pepper said. The vast majority were from the South, primarily Tennessee, followed by Mississippi, Arkansas, and Kentucky. In total, the clinic saw patients from 21 states, mostly across the South and the Midwest.

Absorbing patients who would need to travel north for abortion care was precisely the goal.

“We wanted to take care of the same communities that we had been taking care of for the last 50 years,” Pepper said. “I think most folks in Illinois, like in all states, knew who their abortion providers were, who had been in their communities for decades. And so I think folks in Illinois are continuing to go to those colleagues of ours, and we are really taking care of folks, primarily, that are having to travel outside of their communities to access care.”

Expanding capacity

Other longtime abortion providers in Illinois have expanded their staff and capacity to handle the influx of out-of-state patients and avoid displacing locals. Illinois’ oldest independent clinic, Hope Clinic in Granite City—just across the border from Missouri—has increased its staffing by 40 percent and added an additional clinic day to handle increased patient volume, Chief Operating Officer Michele Landeau said.

Caring for out-of-state patients—particularly Missourians—is nothing new. But the number of out-of-state patients has skyrocketed in the last two years.

“Since the Dobbs decision, we have seen patients from 28 different states and four different countries,” Landeau said. “A lot of them are coming from the Southeast, but a lot of folks are coming from other states in the Midwest.”

Hope Clinic has also increased its capacity to offer care up to 27 weeks, six days of pregnancy.

“We have seen a 250 percent increase in the number of people who are seeking care in their second trimester at Hope Clinic,” Landeau said.

Family Planning Associates (FPA) in Chicago is the Midwest’s largest independent abortion clinic, and it’s another one of the few outpatient providers for later second trimester abortions in the state. To accommodate the additional demand, Medical Director Dr. Allison Cowett said FPA has hired 20 additional staff members to bring its staff up to 60 people in total, and increased the size of its physical space.

“Somewhere between 10 and 12 percent of our patients were from out of state prior to Dobbs, and most of those folks were from Indiana and Wisconsin,” Cowett said. “Now, over 30 percent of our patients are coming from outside of Illinois.”

FPA sees about 30 Texans per month, she said, with a growing number from the rest of the South since Florida’s six-week ban went into effect.

Pepper also noted the critical importance of clinics that remain open in states that ban abortion, such as West Alabama Women’s Center, Feminist Women’s Health Center in Atlanta, and Women’s Health Center of West Virginia, so patients will have safe places to go for follow-up care if needed once they return home, or if they self-manage their abortions.

Cowett said she had a patient recently whose experience points to this need. The patient traveled from the Deep South to Chicago for her abortion, and she was concerned about the amount of bleeding she was having when she returned home. After evaluating her symptoms, Family Planning Associates staff determined it would be best for her to seek care.

“The physician that she saw in the emergency room close to her house called the police,” Cowett said. “She did not even tell them that she had had an abortion … luckily the police, in that situation, didn’t feel compelled to act on being called. But she left the emergency room without getting any care.”

After several more attempts to get the patient care near her home, she ended up traveling all the way back to Chicago.

A growing need for hospital-based care

Abortion bans are well known to delay patients, forcing them to seek care later in pregnancy than they otherwise might have. And when patients have more complex medical needs, they sometimes need care in a hospital rather than in a clinic setting.

“Sometimes that is because the pregnancy is further along, but it might be because of a health condition,” said Qudsiyyah Shariyf, deputy director of the Chicago Abortion Fund (CAF). “There are some health conditions where if that person had stable health care, they might not have needed hospital care. But so many people, particularly from the South and Midwest, and in rural areas, don’t have access to health care, and so when they’re showing up to get an abortion, that might be the first time in a long time that they’re seeing a doctor.”

To help facilitate access to hospital-based care, the state of Illinois set up the Complex Abortion Regional Line for Access (CARLA), a referral line that helps people secure appointments and access funding through CAF.

Illinois’ state government has been proactive and supportive, Pepper said. However, some gaps remain. For example, Landeau said, when a patient does arrive at Hope Clinic with a complex case that requires hospital care, they have to be referred five hours north to hospitals in Chicago despite the fact that there are plenty of hospitals in Southern Illinois.

“I think the state is aware of it and is taking it seriously because they take abortion access seriously,” she said. Just this week, Gov. J.B. Pritzker signed a new slate of abortion and birth justice protections into law, including a requirement that Illinois-based insurance plans cover abortion with no copays or deductibles.

A regional hub for abortion support

To meet the demand for financial support in its abortion “destination” state, CAF has built itself into a regional hub for abortion funding and support. It has partnered with several smaller abortion funds, helping them to streamline and scale up their operations.

For example, CAF partnered with Wisconsin Abortion Fund while abortion was inaccessible there, and it currently partners with Nebraska Abortion Resources and Arkansas Abortion Support Network, Shariyf said.

With Iowa’s six-week ban now in effect, IAAF becomes the latest fund to enter into such a partnership.

“The only thing that’s going to change on our end is the phone number that people call,” IAAF’s Lenz said. “We are still raising money and we’re still providing money for Iowans who need abortion care.”

Since the Dobbs decision, CAF has heard from about 450 Iowans, a number it now expects to increase, according to Shariyf. In the partnership, CAF will take on all the case management duties for IAAF’s clients, allowing IAAF to focus its efforts purely on raising and distributing funds.

According to Shariyf, this just makes sense: In addition to Illinois being a safe haven for abortion care, CAF is a larger fund with a mix of volunteer and paid staff, as opposed to smaller funds like IAAF, which are typically all-volunteer. The partnership model smooths the process of interstate travel for patients, reducing the number of phone calls they have to make in order to get the financial help they need. It also gives smaller funds access to CAF’s more robust infrastructure and reduces the administrative burden on clinics, Shariyf said.

Will the money run out?

“The biggest problem right now is the funding,” Cowett said.

“Abortion funds have done an amazing job raising money and helping people understand how important it is for outside philanthropic efforts to meet the needs of these people who are traveling,” she continued. “But the money and the resources are finite. There will be a time where it’s difficult to provide funding for these people to travel.”

That’s especially true given the growing number of patients who need care later in pregnancy—when procedures take longer and are more expensive—or in hospitals.

“Our hospital patients make up about 2 percent of our callers and over 20 percent of our budget,” Shariyf said.

For months, abortion funds and clinics alike have sounded the alarm that post-Dobbs “rage” donations are drying up. The situation has only been made more difficult by the fact that recently, the National Abortion Federation—the biggest player in the abortion funding space—confirmed to Rewire News Group it cut the amount of assistance it is able to give per patient from up to 50 percent of the total cost to up to 30 percent.

“At this point, Chicago Abortion Fund is really fortunate to have city, state, and foundational investment in our organization and in the abortion access ecosystem in Illinois,” Shariyf said. “And still, the increase in our services post-Dobbs is not sustainable without longer-term policy change.”