For seven months, two public health crises enveloped in South Dakota: the COVID-19 pandemic and no abortion care.

According to the Guttmacher Institute, the average one-way driving distance for abortion patients in South Dakota is 92 miles—the third longest in the country.

After the staunchly anti-abortion judge Amy Coney Barrett was nominated to the Supreme Court in late September, advocates warned her confirmation would mean the end of Roe v. Wade, the landmark 1973 Supreme Court decision that affirmed the right to abortion. Not getting similar headlines was the fact that, even with Roe still on the books, one U.S. state had gone for more than six months without abortion access already.

South Dakota has just one abortion clinic, Planned Parenthood in Sioux Falls, near the state’s eastern border with Minnesota and Iowa. But there’s no permanent doctor to provide care in the state. The organization typically flies in abortion providers from Minnesota, but due to the COVID-19 pandemic, they halted that travel in March. At that point, South Dakota became the first state since Roe to have zero abortion access for an extended period of time. In a preview of a post-Roe future, everyone seeking an abortion had to travel out of state—that is, if they had the resources to do so. Only in October was the clinic able to partially reinstate abortion procedures, offering care just one day per month, thanks to a doctor driving at least four hours each way.

Access was “hanging by a thread before and it’s hanging by a shredded thread now because of the pandemic,” said Sarah Stoesz, president and CEO of Planned Parenthood North Central States, which represents Iowa, Minnesota, Nebraska, North Dakota, and South Dakota.

Thanks to South Dakota’s intense abortion restrictions, many people were traveling out of state for care even before the pandemic. The state requires patients to undergo counseling 72 hours before their procedure, not including weekends and holidays—it’s the most restrictive waiting period in the country. That counseling must be done in person, which effectively bans prescribing abortion medication via telemedicine, and the physician providing the abortion, not a nurse or another staffer, must do the state-mandated counseling.

This web of regulations meant that the Sioux Falls clinic did counseling on Mondays and procedures on Thursdays, providing abortions just one day per week pre-pandemic. The practice isn’t big enough to hire a full-time doctor, and pro-choice doctors in the state are prohibited by their health system employers from providing abortion on the side, Stoesz said. So Planned Parenthood has flown in providers from other states ever since they took over the clinic in 1995. In recent years, Minnesota-based providers flew in on Monday morning and flew home that night, and again on Thursdays.

Then COVID-19 hit. In March, the clinic’s medical director made the decision to stop travel out of concern for provider and patient safety. Plus, the doctors who fly to South Dakota needed to stay well in order to serve patients in Minnesota.

“There’s no good answer here,” Stoesz said. “There’s a terrible provider shortage, and so we have to be very, very careful with our physician resources. Having a physician get sick and not be able to work would impact many, many people.”

The clinic can’t treat patients virtually because of a state ban on the practice; South Dakota is one of 19 states that bans telemedicine for abortion.

“It would be a perfect solution if we could use telemedicine abortion but we can’t,” Stoesz said. As a workaround, in June they were able to reopen an Iowa clinic 85 miles away to offer medication abortion. The Sioux Falls providers are driving to that clinic, which had shut down in 2017 after Iowa lawmakers defunded Planned Parenthood. But it’s still very far for people in the northern and western parts of the state, so they’re also referring people to their nearest clinic across state lines.

Then, in October, a Minnesota provider started driving in one Monday and Thursday each month in order to have one day of on-site procedures. After seven months without access, Sioux Falls is back to providing about 10 to 15 abortions on that single day per month.

One of the board members of a new South Dakota abortion fund, the Justice through Empowerment Network, or JEN, acknowledged that COVID-19 is out of control in the state. But while provider safety is important, she said, the decision to halt procedures had a huge impact on patients who now have to cross state lines to get care.

“It’s a bad situation for everybody right now,” said Emily, whose name has been changed to protect her privacy. “People went from having to drive two or three hours to, like, seven. To get from Pierre, South Dakota, to St. Paul, Minnesota, is a pretty good trek.”

Elizabeth Nash, interim associate director of state issues at the Guttmacher Institute, said South Dakota lawmakers have passed 38 abortion restrictions since Roe. That’s a lot less than, say, Louisiana with 89, but Nash said that doesn’t show the whole picture.

“Then you layer in, what does access look like, and the geography of the state, because it is so big,” Nash said. “Then you start to see just how inaccessible abortion is for people in South Dakota. It’s incredibly difficult.”

Insurance plans sold through the state’s Affordable Care Act marketplace can only cover abortion in cases of life endangerment or severe risks to the pregnant person’s health; the state’s Medicaid program only covers abortion if a person’s live is in danger, in violation of the federal Hyde Amendment standards. Even though it’s technically still a legal right in South Dakota, just 332 residents had an abortion in the state in 2019.

According to a Guttmacher analysis published in April, the average one-way driving distance for abortion patients in South Dakota is 92 miles—the third longest in the country, behind North Dakota and Wyoming. When the state’s sole clinic wasn’t offering procedures, that distance more than doubled to 188 miles.

“Telehealth should be available in this situation,” Nash said. “Making health care easier to access has been a huge part of what we’ve seen in the coronavirus response, but not so much when it comes to abortion.”

A post-Roe reality

The COVID-induced barriers in South Dakota are a view into a post-Roe world, a world in which many people already live, Nash said.

“In many ways, South Dakota, and other states in the South, Midwest, the Plains, were already in a world where abortion access is so limited, it is much like what it was before Roe: Abortion is not legally banned, but accessing services is so difficult that for some people they cannot do it,” Nash said.

Emily agrees, and that’s why she and a group of other activists formed JEN. They used to be involved with the state’s now-defunct affiliate of NARAL Pro-Choice America and started talking last December about forming a new group since, as Emily says, NARAL was mostly focused on politics. While they understood the need to work on political goals like repealing the state’s “trigger law,” which would ban abortion if Roe is overturned, that work would take years and people were being oppressed now.

“We just kind of felt useless,” she said. “We saw people needing help accessing care and we decided that we just wanted to have the freedom to do what we felt would be most helpful.”

Through donations, JEN can help people pay for the many expenses associated with getting an abortion. (The fund is named after Emily’s former co-worker, who died suddenly and was passionate about abortion access.)

“We knew that there was a need for not just procedure funding, but also transportation, childcare, lodging—especially with the 72-hour waiting period,” Emily said.

Depending on funding availability, JEN helps pay for the procedure and sometimes travel. They’ve partnered on a few clients with the Midwest Access Coalition, a practical support group that helps organize and pay for travel and lodging. JEN can also help people pay for birth control and emergency contraception, since a major insurance plan in the state is offered through a Catholic health system and doesn’t cover contraception.

Since starting in March, JEN has helped a handful of people. “We haven’t had a lot of people call us because a lot of people don’t know about us yet,” Emily said.

The state’s long-standing abortion fund, South Dakota Access for Every Woman, has seen an uptick in calls this year amid the pandemic, said Evelyn Griesse, who runs the fund along with her sister Ann. They started in 1985 and offer funding between $100 and $300 for people having procedures in the same five states served by the regional Planned Parenthood network: Iowa, Minnesota, Nebraska, North Dakota, and South Dakota.

Griesse said South Dakota’s abortion restrictions are disrespectful to women.

“I really wish that legislators would have to live six months hoping that they can get their rent paid, and that the car doesn’t break down, and that the abusive partner goes away, and all those sorts of things,” Griesse said.

She added that, through October, the fund has helped 152 people, more than the total they served the past four years. People calling the fund for help say they’ve lost their jobs or are making less money, Griesse said.

It’s OK to have an abortion

Indigenous people face even greater economic challenges, said Charon Asetoyer, executive director and CEO of Native American Women’s Health Education Resource Center (NAWHERC), a South Dakota-based nonprofit that successfully sued the Indian Health Service to get IHS to provide emergency contraception in all its clinics. Native people made up 9 percent of the South Dakota population in 2018.

Many Native women don’t have health insurance because they get medical care through IHS, Asetoyer said. IHS facilities are supposed to provide abortions in cases of rape, incest, and life endangerment (following the Hyde Amendment rules), but according to the most robust study to date, only 5 percent of contacted IHS facilities provided abortion on site even in those limited circumstances.

This means most Native women have to travel to a non-IHS clinic for an abortion, and “generally speaking, you’re really stuck with having to pay full cost,” Asetoyer said. On top of the insurance coverage barrier, there’s the fact that Native women typically earn only 60 cents for every dollar paid to white, non-Hispanic men, according to the National Partnership for Women and Families. For comparison, white women make 79 cents for every dollar that white men do.

Asetoyer, who is a citizen of the Comanche Nation, said women are contacting her group on a regular basis for help in figuring out how to get abortion care during the pandemic.

“It’s almost impossible to get an appointment up in Sioux Falls,” she said. “If they can go to Omaha—if they’ve got the resources—they’ll do it, but if they don’t, they don’t have much alternative. It’s been really, really heartbreaking.”

Asetoyer compared the pandemic situation in South Dakota to life before Roe, when women with money flew to Canada or Europe for abortions while people with fewer resources were left to use non-legal channels or give birth.

“Women have wanted them, but can’t afford to leave the area,” Asetoyer said. “And by being down a provider, it’s made it even more difficult to access. So it has been a huge burden on women.”

There are also women in the community who have several children and want their tubes tied, but IHS refuses to do it: Some IHS facilities contract providers through Avera Health, a Catholic system, and those providers comply with the Catholic health directives that ban sterilization, Asetoyer said. It’s also possible that IHS doesn’t want to be accused of anything untoward, given the country’s dark history of forcibly sterilizing Native women. Their choices are also gone.

Griesse was grateful to see a spurt of donations, from both private foundations and individual donors, after Justice Ruth Bader Ginsburg’s death, and that will help meet the increased need this year.

Griesse is hopeful that a COVID-19 vaccine will help return some semblance of normalcy, but normal was already hard. Improving access in the state long-term will be an uphill battle, thanks to the huge amount of anti-abortion stigma. Stoesz calls the region “the Northern Bible Belt” and pointed to the tradition of father-daughter Purity Balls, with public pledges of abstinence until marriage.

“People don’t want to share about how hard it is or do anything [to improve access] because you don’t want to draw attention to yourself as being somebody who needed abortion services,” Emily, the JEN board member, said.

To spread the word about JEN and address the stigma problem, the group purchased eight billboard ads in Sioux Falls over the summer that read, “It’s OK to have an abortion.” They plan to buy more ad space across the state.

Emily has seen online comments saying that people should just move out of South Dakota if they don’t like its abortion laws.

“Pardon my language, but that’s bullshit,” she said. “I grew up here, my parents live here, my grandparents lived here, my great grandparents lived here. Why should I have to move away from my family and raise my daughter away from her grandparents because you don’t want to give me my basic human rights?” She’s staying to fight.