Inside Planned Parenthood’s Birmingham, Alabama, clinic, a quiet space with few windows and stock photos of the city lining the walls, a woman taps her hand against her stomach as Dr Shelly Tien performs a surgical abortion.
Tien flew to Birmingham the day before, and she will return home to Jacksonville, Florida, that night. A week earlier, she performed abortions at a clinic in Oklahoma. She’s among an estimated 50 doctors who travel across state lines, according to the National Abortion Federation, to provide abortions in places with limited abortion access.
“You’re doing great,” Tien tells the woman on the examination table. “So strong. Breathe. Excellent job.”
A maternal-foetal medicine specialist, Tien spends hours power-walking through airports, driving rental cars and FaceTiming her boyfriend from hotels so she can help women end pregnancies where they otherwise could not because no local doctors are able or willing.
Tien allowed Reuters to accompany her as she travelled from Florida to Alabama to provide abortions in March and to observe her work in Oklahoma in December.
The window for such trips could be closing. The US Supreme Court’s conservative majority has signalled a willingness to overturn or weaken the 1973 Roe v Wade ruling that legalised abortion nationwide.
Anticipating that decision in a Mississippi case this spring, conservative lawmakers have passed a flurry of new abortion restrictions. Approximately two dozen states – including Oklahoma and Alabama – have laws that position them to further limit abortion access should the constitutional right be overturned.
As Tien watched abortion access wane in recent years, she decided to help fill the gap.
In February 2021, Tien started flying from her Illinois practice for high-risk pregnancies to Oklahoma City to perform abortions at the Trust Women clinic. The following month, she moved to Florida with her dog to take a full-time job at Planned Parenthood in Jacksonville. In December, she added trips to Birmingham.
She is reluctant to speculate about what her life would look like in a post-Roe world. She worries some women will resort to unsafe means to end their pregnancies.
“My plan is to always do abortions,” she says. “I’ll do it legally, and I’ll follow whatever state restrictions and regulations are in place. What that actually will look like, I’m not entirely sure.”
Stigma and safety
Abortion clinics in at least six states – including those in Oklahoma and Alabama where Tien works – rely entirely on out-of-state doctors to provide abortions.
Safety concerns and the stigma around abortion keep many local doctors in conservative states from performing abortions, said Zack Gingrich-Gaylord, a spokesperson for Trust Women Oklahoma.
It can take months for the travelling doctors to obtain the licences and credentials needed to work in any given state, and longer if the state has laws requiring abortion doctors to have admitting privileges at local hospitals.
Only two states – North Dakota and Missouri – have hospital admitting privilege requirements in effect. Others have been blocked by courts, including similar laws in Texas and Louisiana struck down by the Supreme Court in 2016 and 2020, respectively.
Abortion opponents say such rules protect women who might have dangerous complications after an abortion and need follow-up care. Nearly 630,000 abortions were performed in the United States in 2019, the most recent data available from the Centres for Disease Control and Prevention (CDC) showed. That’s more than one abortion every minute.
If the doctor who performed the procedure leaves the state soon after, “continuity of care and the ability to have medical oversight that spans longer than one hour” become a concern, says Sue Swayze Liebel, state policy director for the anti-abortion group Susan B Anthony List.
Abortion rights advocates point to studies that show abortion complications are extremely rare, and abortion is much safer than childbirth. Clinics also have follow-up protocols for emergency cases. The CDC identified two abortion-related deaths in 2018 in its most recent annual report.
At the Birmingham clinic, Tien sees patients from across Alabama, as well as from Mississippi, Louisiana, Georgia and Texas, states that also restrict abortion. The women must time their appointments to coincide with visits from one of the travelling doctors, and also factor in the 48-hour waiting period Alabama requires between their initial appointment and their abortion appointment.
Tien’s day of appointments in March includes six surgical abortions and 12 by medication.
The patients range in age from 19 to 36. One woman has driven several hours from Louisiana. Another is on the phone trying to come up with enough money to pay for abortion pills. A patient who spoke only Spanish communicates with nurses through a translation phone line.
In a private office, Tien sits across a table from AW, a local woman with two young kids, ages four years old and eight months.
AW, who asks to go by her initials for privacy, says the father of her latest pregnancy isn’t financially stable. She hasn’t told him about her decision to get an abortion.
“I felt as if he was going to try to make me change my mind,” she says. “I don’t want to change my mind.”
Tien hands AW a mifepristone pill to swallow. She instructs AW to take misoprostol pills at home the next day to complete the abortion and warns AW might experience intense cramping.
“Women are very strong,” Tien tells her. “Women do this every day.”
Tien says she was adamant from a young age that women should have control over their bodies and pregnancies. She once read a saying she felt summed up her sense of calling: “Medicine = science + love”.
Tien knows she could be targeted for her work and takes precautions accordingly. Planned Parenthood reimbursed her for a home security system after she was hired in Florida. She tries to keep at least a quarter of a tank of petrol in her car in case she needs to get away from someone following her.
At the Oklahoma City clinic, a full-time security guard checks the bags of everyone who enters the building. In Jacksonville, Tien enters the clinic through a back door, away from the cluster of anti-abortion protesters who often stand outside.
On a visit in March, one woman outside the clinic holds a sign reading, “Life, the first inalienable right.”
By evening, the Birmingham clinic is empty. Tien picks at a bagel in her office and checks her phone.
Her flight to Atlanta is delayed, meaning she is likely to miss her connection back to Jacksonville. She is scheduled to perform abortions there the next morning, 400 miles (645 km) away.
“What’s the fastest way back to Jacksonville from Atlanta – driving or early am flight?” she asks in a text message to her boyfriend.
She decides to fly.
“One thing I don’t have stamina for is driving,” she says.
Tien calls the Jacksonville clinic manager to say she will be late for the morning appointments.
But the flight to Atlanta ends up arriving close to on-schedule after all. Tien races through the airport, her turquoise backpack bouncing on her shoulders, and makes her connection to Jacksonville with minutes to spare.
Photography by Evelyn Hockstein, Reuters