Taniya, an ultrasound sonographer, guides resident Dr. Ericka during an ultrasound on a patient from Austin, Texas, before her surgical abortion at the Trust Women clinic in Oklahoma City, U.S., December 6, 2021.
Taniya, an ultrasound sonographer, guides resident Dr. Ericka during an ultrasound on a patient from Austin, Texas, before her surgical abortion at the Trust Women clinic in Oklahoma City, U.S., December 6, 2021. Reuters / EVELYN HOCKSTEIN

Inside Planned Parenthood's Birmingham, Alabama, clinic, a quiet space with few windows and stock photos of the city lining the walls, a woman tapped her hand against her stomach as Dr. Shelly Tien performed a surgical abortion.

Tien, 40, had flown to Birmingham the day before, and she would 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 told the woman on the exam table. "So strong. Breathe. Excellent job."

A maternal-fetal 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 traveled 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 U.S. Supreme Court's conservative majority has signaled a willingness to overturn or weaken the 1973 Roe v. Wade ruling that legalized 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. Oklahoma lawmakers could also pass a bill as soon as this week banning almost all abortions, effective immediately.

As Tien watched abortion access wane in recent years, she decided to help fill the gap.

In January 2021, Tien left her Illinois practice for high-risk pregnancies and moved to Florida with her dog to take a full-time job at Planned Parenthood in Jacksonville. The following month, she started flying to Oklahoma City to perform abortions at the Trust Women clinic. 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 said in an interview. "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 traveling doctors to obtain the licenses 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 Centers 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, said Sue Swayze Liebel, state policy director for the anti-abortion group Susan B. Anthony List.

Abortion rights advocates point to studies https://pubmed.ncbi.nlm.nih.gov/26241413 that show abortion complications https://pubmed.ncbi.nlm.nih.gov/22270271 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 traveling 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 included six surgical abortions and 12 by medication.

The patients ranged in age from 19 to 36. One woman had driven several hours from Louisiana. Another was on the phone trying to come up with enough money to pay for abortion pills. A patient who spoke only Spanish communicated with nurses through a translation phone line.

In a private office, Tien sat across a table from AW, 22, a local woman with two young kids, ages 4 years old and 8 months.

AW, who asked to go by her initials for privacy, said the father of her latest pregnancy wasn't financially stable. She didn't tell him about her decision to get an abortion.

"I felt as if he was going to try to make me change my mind," she said. "I don't want to change my mind."

Tien handed AW a mifepristone pill to swallow. She instructed AW to take misoprostol pills at home the next day to complete the abortion and warned AW might experience intense cramping.

"Women are very strong," Tien told her. "Women do this every day."

Tien said 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 tank of gas 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 held a sign reading, "Life, the first inalienable right."

TRAVEL WOES

By evening, the Birmingham clinic was empty. Tien picked at a bagel in her office and checked her phone.

Her flight to Atlanta was delayed, meaning she would likely miss her connection back to Jacksonville. She was 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 a.m. flight?" she asked in a text message to her boyfriend.

She decided to fly.

"One thing I don't have stamina for is driving," she said.

Tien called the Jacksonville clinic manager to say she would be late for the morning appointments.

But the flight to Atlanta ended up arriving close to on-schedule after all. Tien raced through the airport, her turquoise backpack bouncing on her shoulders, and made her connection to Jacksonville with minutes to spare.