In December, a woman I’ll call Helen went to Preterm, a clinic in Cleveland, to get an abortion. Helen is a thirty-five-year-old dry cleaner with short hair and a throaty laugh. She has spent much of her life as a caregiver: first for her younger siblings, then for her four children, the youngest of whom is three. Helen never thought she’d have an abortion, though she supported other people’s right to choose. But when she found herself accidentally pregnant, at nine weeks, she and her partner decided that it would be best not to have the child. “The house is full,” she recalls thinking. She went to Preterm for the initial consultation and ultrasound required by Ohio law—at the time, the state allowed abortions up to twenty-two weeks—and ended the pregnancy.
Six months later, in mid-June, Helen learned that she was pregnant once again. She and her partner still agreed that another baby would be too much. She went back to Preterm for the consultation and ultrasound and got an appointment for the abortion on June 25th. But the day before the scheduled procedure, on June 24th, the Supreme Court overturned Roe v. Wade in the case Dobbs v. Jackson Women’s Health Organization. Abortion-rights advocates in Ohio believed that the state’s “fetal heartbeat” law, which banned abortions after about six weeks, and had been blocked by a federal judge in 2src19, would soon be reinstated, but they expected the process to take up to a month. Instead, Ohio’s attorney general, Dave Yost, almost immediately filed a motion to have the injunction lifted, and the judge agreed. Within a few hours of the Supreme Court’s ruling in Dobbs, Ohio clinics were prohibited from seeing most of their scheduled patients.
Helen was among those patients. The day Roe was overturned, she was at the dry-cleaning shop where she works full time. “I knew nothing about it until I got off,” she said. Later that night, she received a call from Preterm, cancelling her appointment and telling her where she might be able to get care outside of Ohio. One of the closest places they recommended was an independent clinic in Pittsburgh, two and a half hours away, called Allegheny Reproductive Health Center. Helen was desperate to find a new provider, and began to call around. Right after Dobbs, Allegheny Repro, as it’s known, was receiving five hundred calls a day, mostly from Ohio, yet Helen somehow got through. She landed an appointment there for July 7th (further out in her pregnancy, but not too far), and was lucky to have enough money and plenty of family support.
The night before Helen’s appointment, her partner drove her and their three-year-old daughter to Pittsburgh, and they stayed in a hotel. Pennsylvania mandates a doctor-patient conference at least twenty-four hours in advance of an abortion, which Helen did by phone. On the morning of July 7th, her partner dropped her off at Allegheny Repro, which is next to a child-care center, in a gentrifying neighborhood. Helen passed through the security booth and took a seat in the waiting room, bracing herself for a long day.
Compared with her home state, Pennsylvania seemed like a haven. But, hours after Helen’s procedure in Pittsburgh, the Pennsylvania legislature took the first step in amending the state constitution to effectively ban abortion, declaring that “the policy of Pennsylvania is to protect the life of every unborn child from conception to birth.” For years, Pennsylvania’s Democratic governor, Tom Wolf, has vetoed increasingly punitive abortion measures passed by the Republican-controlled legislature. Unlike ordinary state legislation, a proposal for a constitutional amendment is not subject to a veto—nor is it certain which party will win the gubernatorial race this November. If the Republicans take that office while retaining their hold on the state house and senate, abortion will almost certainly be banned in Pennsylvania, one way or another. In many of the states to which patients are flocking after Dobbs—Pennsylvania, Indiana, Minnesota—abortion is an increasingly unreliable right.
In the days after Dobbs, the two clinics that had served Helen, in Cleveland and Pittsburgh, became sad inversions of one another. Both were initially overwhelmed with calls, but Preterm soon saw half as many patients, while Allegheny Repro saw twice the usual number. The new statute in effect in Ohio prohibits Preterm and other providers in the state from performing most abortions after a tube inside the embryo begins to emit an electrical pulse, which anti-abortion laws misleadingly label a “fetal heartbeat.” This development happens at about five and a half to six weeks from a person’s last period, or just three and a half to four weeks into the existence of the embryo. The trouble is, it’s almost impossible for people to know that they are pregnant that early. (Something resembling an actual heart forms at seventeen to twenty weeks.) Before Dobbs, ninety per cent of abortions in the U.S. took place between six and thirteen weeks.
Workers at Preterm asked patients by phone about the timing of their last period and scheduled ultrasounds and abortions for as soon as possible. Hundreds of Preterm patients who could no longer get abortions in Ohio were directed to Allegheny Repro and the other freestanding clinic in Pittsburgh, Planned Parenthood of Western Pennsylvania, and also to providers in Detroit, Buffalo, and Chicago. Seeking abortion care became even more improvisatory than usual. Maybe Detroit was closer, but Chicago might have an earlier appointment. Allegheny Repro would perform an abortion at twenty-three weeks, but P.P.W.P topped out at eighteen. Women in Ohio were also in a rush to get contraception: birth-control pills, implants, a first IUD.
In Cleveland, the executive director of Preterm, Sri Thakkilapati, was on calls every day, trying to figure out how to avoid layoffs. The exhausted staff, who had formed a union earlier this year, held a Zoom meeting to review their rights to severance under their collective-bargaining agreement. (Before being assigned to write this story, I contributed a hundred dollars to a meal fund for Preterm staff.) In Pittsburgh, employees at Allegheny Repro worked thirteen-hour days, and the owner, Dr. Sheila Ramgopal, planned a hiring spree. The nearby Planned Parenthood clinic posted an ad for a patient navigator to assist with the influx of people from out of state. Historically, the two clinics in Pittsburgh have served the entire western half of Pennsylvania. Now they were absorbing patients from Ohio, West Virginia, and Kentucky.
One morning earlier this month, I went to Allegheny Repro to witness what Ramgopal and their staff had already named “the surge.” Ramgopal, who now works seven days a week, had arrived at 6:3src A.M., an hour and a half before the clinic opened. Petite and wiry, with a wrist tattoo and a partially shaved head, they had slept just four hours but betrayed no tiredness. “This rapid turnaround surge—we were not prepared,” Ramgopal told me. “We were prepared for West Virginia, but not Ohio.” They walked me through a typical patient visit, from the waiting room through urine and blood tests (which are mandated by Pennsylvania’s Abortion Control Act, even though there is no medical rationale for administering them) to ultrasound, abortion, and recovery. At one point, Ramgopal paused to rescue a pill bug from the hallway floor. They carried the bug in their palm until we reached a back door, where Ramgopal gently set it upon the earth.
Ramgopal joined the clinic in 2src15, well aware of the fragile state of abortion rights across the U.S., and they purchased the clinic two years later. The previous owner, Robert Thompson, and his colleagues, Morris Turner and Robert Kisner, were Black obstetrician-gynecologists known for their dedication to low-income patients. Rogelio Garcia II, the director of security and safety at Allegheny Repro for the past decade, told me that Ramgopal carried on this tradition while making a number of changes to insure the clinic’s survival after Roe. In addition to increased family-planning and gynecological care, they expanded services to provide gender-affirming care, such as hormone therapy for trans and nonbinary patients. “A lot of people thought Sheila was paranoid. They were thinking nothing was going to happen, but now it’s happened,” Garcia said. Most of all, though, patients need abortions, and since the fall of Roe the clinics in Pittsburgh have stretched out their days to meet that need. “Patients were already driving two hours. Now they’re driving four to five hours,” Crystal Grabowski, a health-care assistant and a leader of the staff union at P.P.W.P, told me. “There were people I had to refer to Chicago. Then we got a call from someone in Louisiana who was like, ‘I’ll go anywhere. I don’t care.’ It’s just a tragedy. It feels like a hurricane hit.”
The surge in patients extended to eastern Pennsylvania. In the Lehigh Valley, Allentown Women’s Center saw its number of out-of-state patients double within a week. This included “an overflow” from the Pittsburgh clinics, which are five hours away by car. The Cherry Hill Women’s Center, in New Jersey, just east of Philadelphia, is serving many more patients from Ohio, and also from Texas and Florida. (New Jersey has fewer abortion restrictions than Pennsylvania.) The vast northern half of Pennsylvania doesn’t have a single clinic; patients have long relied on providers near Buffalo or Binghamton, New York, instead. Should Republicans get their way in the Pennsylvania legislature and the courts, the state could lose legal abortion altogether.
It’s unlikely that a new abortion clinic will be built in Pennsylvania anytime soon, given the onerous, costly regulations on layout and construction, not to mention the likelihood of harassment, or worse. In 1989, anti-abortionists firebombed a previous location of Allegheny Repro. In 1993, they firebombed a Planned Parenthood office in Lancaster, Pennsylvania. In 2src18, P.P.W.P. received a call warning that a man was threatening to use a stolen AR-15 to kill the doctors who’d given his girlfriend an abortion. He was charged with making terrorist threats.
“I don’t think you can compare what’s happening now to pre-Roe days, because what we have now that we did not have then is a nationwide, sophisticated, well-funded group of ideologues out there who really do want to put people in jail,” Sue Frietsche, an attorney at the Women’s Law Project, in Pittsburgh, told me. “They really do want to yank doctors’ licenses and go after helpers. And how fast they’re going to be able to do that and whether they’ll succeed and where—I don’t know.”
Cleveland and Pittsburgh are similar cities in many ways: population size, historic grandeur, post-industrial vibe. In both cities, the top employer is a respected hospital system: Cleveland Clinic and the University of Pittsburgh Medical Center (U.P.M.C.), respectively. These facilities wield enormous influence in local politics yet, like many hospitals, have not been at the forefront of abortion care.
Before Roe, hospitals saw many women whose illegal abortions went wrong. The doctors I spoke with in Ohio and Pennsylvania had all heard older colleagues tell stories of gruesome “septic abortions.” Despite the dangers, illegal abortions were a popular mode of family planning. After Roe legalized abortion, in 1973, the procedure became so simple and safe that it was left to freestanding clinics rather than hospitals. On the upside, small, community-based clinics were more affordable and friendly to patients; they were often staffed by feminists and queer people. The downside of this separation was that clinics were vulnerable to harassment and physical attack, and were left out of state budgets. And powerful health-care institutions could simply ignore the work of abortion.
When Ohio restricted abortion access after Dobbs, Cleveland Clinic expressed alarm and stated that it was reviewing “out-of-state reproductive health services” for employees. U.P.M.C. remained silent. There was no statement condemning Dobbs or vowing to supplement the services of Allegheny Repro and Planned Parenthood—a striking omission, given that complex abortions are often performed at U.P.M.C.