Bristelle Larsen lives in Dillingham. Twenty years ago, she became pregnant.
“I was very early on in my pregnancy and knew in my heart that I was not going to be a mom,” she said.
She worked seasonally between fish processing in Dillingham and operating ski lifts in Girdwood — jobs that require physical labor that she couldn’t manage pregnant or with an infant. So, she chose to have an abortion.
She had to travel to Anchorage, one of only three cities in the state that offers them. She was vague about her trip with employers because of the stigma that surrounds abortion.
“I just told them I needed to go to Anchorage for medical, which is really common,” she said.
She stayed at what she called a “shady” hotel because it was affordable, and she paid cash for the procedure. She says she was lucky enough to have $2,000 for travel and the bill.
She said a medication abortion, known as the abortion pill, wasn’t an option for her at that time because she didn’t live close enough to Anchorage. Her doctor didn’t want to send her hundreds of miles back to Dillingham where they couldn’t check on her. But she said she could see some benefits.
“I think it might have been less traumatic physically,” she said. “Not having to go through putting on the gown and going through the whole rigmarole.”
The rigmarole meant she had to watch her ultrasound and wait 24 hours before her procedure.
When she got home a few days later, she said she worked “light duty” at work for a week while she recovered.
That was almost 20 years ago, but the trip would be the same today. More than a quarter of people who seek abortions in Alaska travel more than 30 miles for care, according to Planned Parenthood. In rural communities off the road system, people sometimes have to fly hundreds of miles to the nearest city.
Barriers to care
Abortion is legal in Alaska, but doctors and advocates say it is not equitable or accessible because of the state’s geography and large rural population. And some say a lawsuit joined by the state’s attorney general could limit access even further by asking the U.S. Food and Drug Administration to reverse its approval of mifepristone, a drug that ends pregnancies. Doctors say it’s the most effective abortion pill on the market.
A statement from Alaska Attorney General Treg Taylor says he joined the state in the lawsuit because the federal government allows the pill to be prescribed by mail, which means even people in states where abortion is illegal can get it. That’s not the way most people in Alaska get it — Planned Parenthood, the state’s main prescriber only does so in person — but the lawsuit would still make the pill unavailable to Alaskans.
“Mifepristone is safe. It’s effective. It has been used by more than 4 million people since the FDA approved it more than 20 years ago,” said Rose O’Hara Jolley, the director of Planned Parenthood Alliance Advocates in Alaska. “So this case is baseless. There is no reason from a science standpoint, from a health care standpoint. It is simply about restricting access to abortion, even in states where abortion is legal.”
Geography is one of the barriers to reproductive care in Alaska. Even people in remote areas who choose to end their pregnancies with the pill usually travel because Planned Parenthood doesn’t prescribe it by mail, even though that is legal.
State data shows that roughly 1,200 to 1,300 people seek abortions per year in Alaska. The majority of them use Planned Parenthood, which is also the main provider of clinical abortions in the state. O’Hara Jolley said about half of Planned Parenthood’s patients choose the abortion pill over a clinical abortion.
“There’s so many barriers to access that removing a medically proven safe and effective way to access an abortion is going to disproportionately affect people who are already seeing barriers to care,” said O’Hara Jolley.
O’Hara Jolley said that, especially for people who live in rural areas, the cost of traveling to get care in Alaska is prohibitive. They added that about half of the people who seek abortions already have children, so those parents also have to find childcare. Safety is another barrier: Alaska has among the highest rates of intimate partner violence in the nation, and the risks only go up for pregnant people.
If the lawsuit is successful, O’Hara Jolley said Planned Parenthood will still prescribe abortion pills, but it will have to use a slightly less effective drug if mifepristone is no longer legal. Planned Parenthood would use only misoprostol, which can be up to 10% less effective. They said this will exacerbate current inequities in health care because people will likely need to pay more visits to the clinic.
“Abortion will still be safe and legal in Alaska,” O’Hara Jolley said. “We just will have one less method for people to choose from.”
Politics and medicine
“We need to be very aware of the direction that the legal system is going when it pertains to this sort of thing,” said Dr. Robin Holmes, a primary care provider in Homer. “The overall implication is that politicians took away physicians’ rights to prescribe medications that are safe and effective for purely political reasons.”
The clinic where Holmes works does not provide clinical abortions or prescribe abortion pills. It offers sexual and reproductive care and education for people of all income levels in the southern part of the Kenai Peninsula. It’s the only comprehensive reproductive health care for a region the size of West Virginia, Holmes said. Her role is to guide people who are pregnant through their care options, whether they want to keep their pregnancies or terminate them.
Abortion is protected in the state’s constitution through the right to privacy, but Holmes said that it can be hard to find care that feels private in small towns in Alaska.
“It’s geography, it’s insurance, it’s stigma,” she said. “Alaskans are already so limited in their access to even getting reproductive health care as far as STI screenings or long acting contraceptive options. What we don’t need is to have another political imposition to our health care access.”
She said for Alaskans who live in rural places, time-consuming travel to Juneau, Anchorage or Fairbanks is usually necessary. And for people who want to get an online prescription for the abortion pill, they might not have sufficient internet access.
Holmes counsels people in the same situation as Bristelle Larsen was in Dillingham 20 years ago. That is, people who don’t have ready access to abortion services. Larsen says that navigating travel and care options was hard then, but shame was the biggest barrier for her.
“If you know someone who might be in this situation or opens up to you about the situation, it’s important not to assign judgment to whatever choice they’re going to make,” she said.
She said she knows people who have had abortions have gone on to have children when they were prepared and lead healthy lives.
“It’s not a sentence of doom,” she said.
A decision in the case is expected as soon as the end of this week. It could be a sentence to more medical uncertainty for rural Alaskans.