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Providers are seeing more patients in need of abortions later in pregnancy as abortion bans and restrictions proliferate in US states, all while access to insurance falls.
Those bans and restrictions have also meant that later abortion care access has grown over the past decade in a handful of haven states and cities.
Patients are showing up “later and sicker” in need of reproductive healthcare, said Diane Horvath, cofounder of Partners in Abortion Care in Maryland, the only all-trimester clinic in the US that is owned and operated by women.
About 41 states have abortion bans or significant restrictions at some point in pregnancy. More than 20 million people have lost Medicaid coverage since 2023, while between 3 and 5 million people have lost or dropped their coverage through Affordable Care Act exchanges in recent months.
“People are getting chucked off of Medicaid. The premiums are all going up,” Horvath said. Instead of seeking care early in pregnancy, she said: “They’re just not going in. There’s no place to go.”
The cost of later abortion – which is loosely defined as anything past the first trimester, the time during which the vast majority of abortions occur – tends to rise the later it happens in a pregnancy.
“Sometimes you’re looking at a $22,000 gap with maybe three days to pull together funding,” said Alisha Dingus, executive director of the DC Abortion Fund (DCAF), one of the largest abortion funds in the country. Rising costs and decreasing availability “may create substantial barriers to accessing later abortion care”, a recent Jama study found.
Costs tend to rise later in pregnancy
“Further into pregnancy, the cost of care goes up, the number of providers goes down, and more and more restrictions go into effect,” said Erika Christensen, cofounder of Patient Forward, a group focused on all-trimester abortion access.
The later abortion population is disproportionately young people living below the poverty line in healthcare deserts, Christensen pointed out, adding: “They’re sort of in a perfect storm: they have the least amount of time to find the money for the most expensive care … we’re talking about someone’s abortion costing potentially more than they make in an entire year.”
The challenges to accessing abortion also increase as the weeks progress. Only clinics in four states and Washington DC, offer all-trimester care to all patients.
But even as the health landscape grows more complex, more providers are moving into the gaps.
In Maryland, where there is no viability limit on pregnancy and the state constitution now protects reproductive freedom, two all-trimester clinics serve patients from around the country and the world – Care Reproductive Health Clinic and Partners in Abortion Care. There is also the DuPont Clinic in neighboring Washington DC.
Abortions in later pregnancy happen for all the reasons people seek abortion earlier in pregnancy, Horvath said. Patients learn new information about the health of the fetus or about their own health; they lose their jobs or their homes; their partners become abusive or disappear. For some, particularly children, the pregnancy itself may not be diagnosed until very late.
Pregnancy “can be really dangerous”, Horvath said. “At any point in the pregnancy, abortion is going to be lower risk than continuing the pregnancy.”
People who need abortions now are often forced to wait longer to access care because of legal barriers and difficulty getting and paying for appointments. They might go to several different states seeking care, hitting up against gestational limits at each point. By the time they end up in Maryland, they’re frequently past the second trimester.
“It is a multiday procedure, and the barriers to access it are so high that to get an abortion at that stage of pregnancy is an intentional decision made with a lot of thought and care,” Dingus said. “This is a medical procedure, and people should have the ability to choose what happens to their bodies.”
Yet even among some abortion supporters, she said, there is stigma around later abortion.
When it comes to later abortion, Horvath said, “people can in good faith decide for themselves if that’s something they would ever want to do or need to do” in their own lives. But medical decisions should be left up to the patient and their health provider – not politicians or government officials, she said.
She continued: “When we say: ‘Well, abortions are OK until this point, except for these things’ – then we get into the business of somebody in an office building in Annapolis deciding what they think is a good abortion and a bad abortion. And I realize that not having a set rule is a really uncomfortable thing for people to hold, but the place that I have to land is: I have to trust this pregnant person to make that decision.
“I do not pretend that I know better about someone’s life than they do,” Horvath added.
In 2025, Partners stopped accepting Medicaid for later abortion because they were losing thousands of dollars on each procedure under reimbursement rules, Horvath said. “We need a significant amount of monthly funding support in order to stay open if we’re going to accept Medicaid for two- and three-day [procedure] folks, which is crappy. It hurts access, and it’s awful,” she said.
But they haven’t turned any patients away, she said. “We do work with about 40 different abortion funds, and so we are able to get people, often, fully funded.”
DCAF has been a major source of support – helping to pay, in an average week, for at least 20 people getting care at 28 weeks’ gestation and later, Dingus said.
“Even before Dobbs, there was always a high number of people who traveled to this region for their abortion care because we didn’t have any gestational age bans,” Dingus said. “Probably in the past two years, we’ve seen a pretty significant uptick in people who are needing funding at 30 weeks and later.”
While donations initially ramped up after the Dobbs decision, that funding has slowed to a trickle even as needs have increased, Dingus said. Funds like DCAF “are seeing just more and more people who need our support, and we are feeling the weight of not having the money for all of those people”, she said. “We are seeing much larger gaps than we’ve ever seen.”
‘This is life-saving work’
A decade ago, Christensen needed an abortion at 32 weeks. Back then, there were only two geriatric white men in the world willing to offer later care in “old-timey” clinics that felt like walking “through a portal back in time”, she said. Advocates worried that when those providers died, care would die with them.
“Things are very different now,” Christensen said. “These providers offering modern later-abortion care are younger, they’re more diverse, the majority of them are women, they’re offering trauma-informed care, their clinics are beautiful – you’re walking into a normal healthcare center.”
The Partners clinic, for instance, is decorated in motifs of flying birds; there’s soft lighting and extra phone chargers, reclining recovery chairs and blanket warmers. The clinic offers gowns of all sizes, and patients may change into donated clothing or wash their own clothes in a laundry machine – because some patients bring nothing with them when they step on a plane.
But the focus on comfort goes beyond aesthetics. “We’ve tried really hard to set our clinic up in a way that people know their autonomy is being respected,” Horvath said. “Nothing happens without your permission. You can stop us at any time; you can ask questions at any time.”
Autonomy is central to discussions about abortion – including later abortion, Christensen said. It gets at “the core of whether women get to be people”, she said. “If the best we can do, as the mainstream feminist and abortion movement, is ‘ask state daddy for permission for when and under what circumstances we can end our own pregnancies,’ I think it’s not the conversation that is required for us to be equal free people.”
Recent years have sharply clarified these key questions about abortion rights, she said, noting: “It could always move faster, but progress is progress, and it is changing.”
Horvath’s father is a physician, and practicing medicine always made sense to her. When she began thinking she would focus on later-abortion care, she worried about her and her family’s safety. They still get protesters outside the clinic sometimes.
Then she saw a very young patient, a 12-year-old girl who needed an abortion. Horvath asked her: “What are you looking forward to when you go back home?”
The child said: “I think I just really want to be a kid again.”
That’s when Horvath realized she could never take any other path but abortion care.
“This is sacred work. This is life-saving work,” she said. “This little girl gets to go be a little girl again.”
