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.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Subscribe to KFF Health News’ free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

In the 18 months after Francine Milano was diagnosed with a recurrence of the ovarian cancer she thought she’d beaten 20 years ago, she traveled twice from her home in Pennsylvania to Vermont. She went not to ski, hike, or leaf-peep, but to arrange to die.

“I really wanted to take control over how I left this world,” said the 61-year-old who lives in Lancaster. “I decided that this was an option for me.”

Dying with medical assistance wasn’t an option when Milano learned in early 2023 that her disease was incurable. At that point, she would have had to travel to Switzerland — or live in the District of Columbia or one of the 10 states where medical aid in dying was legal.

But Vermont lifted its residency requirement in May 2023, followed by Oregon two months later. (Montana effectively allows aid in dying through a 2009 court decision, but that ruling doesn’t spell out rules around residency. And though New York and California recently considered legislation that would allow out-of-staters to secure aid in dying, neither provision passed.)

Despite the limited options and the challenges — such as finding doctors in a new state, figuring out where to die, and traveling when too sick to walk to the next room, let alone climb into a car — dozens have made the trek to the two states that have opened their doors to terminally ill nonresidents seeking aid in dying.

At least 26 people have traveled to Vermont to die, representing nearly 25% of the reported assisted deaths in the state from May 2023 through this June, according to the Vermont Department of Health. In Oregon, 23 out-of-state residents died using medical assistance in 2023, just over 6% of the state total, according to the Oregon Health Authority.

Oncologist Charles Blanke, whose clinic in Portland is devoted to end-of-life care, said he thinks that Oregon’s total is likely an undercount and he expects the numbers to grow. Over the past year, he said, he’s seen two to four out-of-state patients a week — about one-quarter of his practice — and fielded calls from across the U.S., including New York, the Carolinas, Florida, and “tons from Texas.” But just because patients are willing to travel doesn’t mean it’s easy or that they get their desired outcome.

“The law is pretty strict about what has to be done,” Blanke said.

As in other states that allow what some call physician-assisted death or assisted suicide, Oregon and Vermont require patients to be assessed by two doctors. Patients must have less than six months to live, be mentally and cognitively sound, and be physically able to ingest the drugs to end their lives. Charts and records must be reviewed in the state; neglecting to do so constitutes practicing medicine out of state, which violates medical licensing requirements. For the same reason, the patients must be in the state for the initial exam, when they request the drugs, and when they ingest them.

State legislatures impose those restrictions as safeguards — to balance the rights of patients seeking aid in dying with a legislative imperative not to pass laws that are harmful to anyone, said Peg Sandeen, CEO of the group Death With Dignity. Like many aid-in-dying advocates, however, she said such rules create undue burdens for people who are already suffering.

Diana Barnard, a Vermont palliative care physician, said some patients cannot even come for their appointments. “They end up being sick or not feeling like traveling, so there’s rescheduling involved,” she said. “It’s asking people to use a significant part of their energy to come here when they really deserve to have the option closer to home.”

Those opposed to aid in dying include religious groups that say taking a life is immoral, and medical practitioners who argue their job is to make people more comfortable at the end of life, not to end the life itself.

Anthropologist Anita Hannig, who interviewed dozens of terminally ill patients while researching her 2022 book, “The Day I Die: The Untold Story of Assisted Dying in America,” said she doesn’t expect federal legislation to settle the issue anytime soon. As the Supreme Court did with abortion in 2022, it ruled assisted dying to be a states’ rights issue in 1997.

During the 2023-24 legislative sessions, 19 states (including Milano’s home state of Pennsylvania) considered aid-in-dying legislation, according to the advocacy group Compassion & Choices. Delaware was the sole state to pass it, but the governor has yet to act on it.

Sandeen said that many states initially pass restrictive laws — requiring 21-day wait times and psychiatric evaluations, for instance — only to eventually repeal provisions that prove unduly onerous. That makes her optimistic that more states will eventually follow Vermont and Oregon, she said.

Milano would have preferred to travel to neighboring New Jersey, where aid in dying has been legal since 2019, but its residency requirement made that a nonstarter. And though Oregon has more providers than the largely rural state of Vermont, Milano opted for the nine-hour car ride to Burlington because it was less physically and financially draining than a cross-country trip.

The logistics were key because Milano knew she’d have to return. When she traveled to Vermont in May 2023 with her husband and her brother, she wasn’t near death. She figured that the next time she was in Vermont, it would be to request the medication. Then she’d have to wait 15 days to receive it.

The waiting period is standard to ensure that a person has what Barnard calls “thoughtful time to contemplate the decision,” although she said most have done that long before. Some states have shortened the period or, like Oregon, have a waiver option.

That waiting period can be hard on patients, on top of being away from their health care team, home, and family. Blanke said he has seen as many as 25 relatives attend the death of an Oregon resident, but out-of-staters usually bring only one person. And while finding a place to die can be a problem for Oregonians who are in care homes or hospitals that prohibit aid in dying, it’s especially challenging for nonresidents.

When Oregon lifted its residency requirement, Blanke advertised on Craigslist and used the results to compile a list of short-term accommodations, including Airbnbs, willing to allow patients to die there. Nonprofits in states with aid-in-dying laws also maintain such lists, Sandeen said.

Milano hasn’t gotten to the point where she needs to find a place to take the meds and end her life. In fact, because she had a relatively healthy year after her first trip to Vermont, she let her six-month approval period lapse.

In June, though, she headed back to open another six-month window. This time, she went with a girlfriend who has a camper van. They drove six hours to cross the state border, stopping at a playground and gift shop before sitting in a parking lot where Milano had a Zoom appointment with her doctors rather than driving three more hours to Burlington to meet in person.

“I don’t know if they do GPS tracking or IP address kind of stuff, but I would have been afraid not to be honest,” she said.

That’s not all that scares her. She worries she’ll be too sick to return to Vermont when she is ready to die. And, even if she can get there, she wonders whether she’ll have the courage to take the medication. About one-third of people approved for assisted death don’t follow through, Blanke said. For them, it’s often enough to know they have the meds — the control — to end their lives when they want.

Milano said she is grateful she has that power now while she’s still healthy enough to travel and enjoy life. “I just wish more people had the option,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Subscribe to KFF Health News’ free Morning Briefing.