Two years ago, California voters overwhelmingly decided that all residents should have access to reproductive health care, including abortion, and enshrined this right in the state constitution. It wasn’t just coastal liberals that supported the measure: Counties in the rural north, Central Valley and Sierra Nevada all voted in favor of the proposition despite also voting largely for Republican offices. But despite the law, residents in many parts of the state still struggle to access reproductive health care. About 40 percent of California counties do not have an abortion clinic. Most of these, including Del Norte, Siskiyou, Trinity, Plumas, Sierra, El Dorado, Tuolumne and Inyo counties, are rural areas where the lack of access can leave residents with few options.

While order-by-mail medication and telehealth appointments have become more accessible in the last few years, rural patients sometimes still have difficulty getting accurate information about the reproductive health care services that are available to them. One solution, health advocates say, could be to allow nurse practitioners and nurse midwives to perform abortions, as approved by the California legislature in 2022. While advocates hope this will help alleviate the shortage of providers, the challenge some rural areas face isn’t in finding a provider with the skills to perform abortions, but the will and space to do so.  

Inyo County, in the Eastern Sierra, has one of the worst access landscapes in the state, with most of its residents living more than 200 miles from the nearest abortion provider. Many residents may not know what services are or are not available until they need them and may be surprised when they realize that not all Californians can easily access abortion care, despite the role of the state in advocating for access.

For K. (who requested that we withhold her name to protect her privacy), the news that she was pregnant last year came as a shock. K. was living in Bishop with her long-term partner, and she thought they were doing what they needed to do to avoid getting pregnant. But, that spring, after she learned she was pregnant, she decided to seek an abortion.

K. assumed that she’d be able to seek care at the Women’s Health Clinic at Northern Inyo Hospital in Bishop, a place she’d received other medical care in the past. But when she called to make an appointment, the clinic told her that they were not able to provide abortions that the clinic deems medically necessary. K. was surprised that abortions weren’t accessible across California given the state’s vocal support for access. K. began researching the nearest clinics. After realizing that she’d need to travel more than 200 miles — likely requiring a stay in a hotel and many hours of travel — she and her partner decided that they’d seek care in Seattle, where they were planning to visit soon. There was a clinic close to where they’d be staying, and it seemed more comfortable to have a home, not a hotel, to recover in.

K.’s procedure went smoothly, but because of the lack of access in Bishop, she had to wait a few weeks longer to have the procedure. K. is content with her decision, but the weeks she spent waiting for and seeking care made the experience much more difficult, both physically and emotionally. “It could have been easy,” she said.

And yet, K. acknowledges how much harder the situation can be for others without the resources she has. She worries about low-income patients, those with work and family responsibilities, and those in abusive relationships, who may not be able to access reproductive health care. The Eastern Sierra’s remoteness is also complicated by the lack of comprehensive public transportation, which makes traveling out of the area more difficult.

Dr. Martha Kim, one of Northern Inyo’s obstetrician-gynecologists, explained the role of small-town politics in making difficult decisions about the availability of reproductive health services, for a story we reported in 2022. Dr. Kim fears that offering elective abortion services could draw negativity or attacks on patients or fellow providers, and despite her personal support for abortion rights, believes that it is, unfortunately, the best thing for the community to only provide pregnancy terminations that the clinic deems medically necessary.

And while abortion rights are not explicitly on the ballot this November in California, new data from the Deliberative Democracy Lab at Stanford University shows that reproductive rights are paramount to first-time voters. In a sample of young voters from across the country, about 80 percent opposed the idea that Congress should pass a nationwide ban on medication abortion. Both Republicans and Democrats supported the idea that the U.S. federal government should create protections for abortions when the pregnancy threatens the mother’s life, and Democratic and Independent voters also supported a law ensuring access to abortion on a national basis.

Despite Californians’ vocal support for abortion access in 2022, little change has been seen in rural parts of the state. The state passed a series of bills, also in 2022, to strengthen abortion access, and experts are hopeful that allowing nurse practitioners and nurse midwives to perform first-trimester abortions without a doctor present will help in rural areas. But while the shortage of providers is a contributing factor in many rural parts of the state, it isn’t the only issue. Dr. Kim and the staff at Northern Inyo Hospital in Bishop are trained and equipped to provide abortions, yet they only do so selectively.

The state also launched a website to help people find their nearest abortion clinic, but as we reported in 2022, the site, through the organization AbortionFinder, uses straight-line directions that provide inaccurate information to many rural residents. In Bishop, for example, the site claims Fresno’s as Bishop’s nearest clinic, at 89 miles away, while Fresno is actually more than 200 miles away driving in the summer when roads through the mountains are open and more than 300 miles away in winter when those roads are closed. Despite acknowledging the problem in 2022, state officials have not updated the website.

Medication abortion, available in California via telehealth, is also an important resource for rural residents. Today, more than half of abortions are performed via medication, but doctors and patients emphasize that medication is not always a substitute for an in-clinic procedure. Many patients prefer to be treated in person, and some doctors say that the surgical procedure can be quicker and easier than taking the medication. Additionally, the medication method is limited to the first ten weeks of pregnancy.

Despite the shortcomings of California’s abortion access in rural areas, patients like K. and doctors like Dr. Kim are still grateful that seeking care did not come with legal repercussions, as it can in some states. Still, they know it’s not easy for patients. In some areas, said Dr. Kim, it’s a resource limitation, but in Bishop? “It’s a social limitation.”