BAKER CITY, Ore. — In what has become a routine event in rural America, a hospital maternity ward closed in 2023 in this small Oregon town about an hour from the Idaho border.

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 JAMA in early December that examined 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. Research has shown 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 2024 March of Dimes report. For people in the Southern states where lawmakers installed abortion bans, abortion care can be up to 700 miles away, according to a data analysis by Axios.

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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