When someone finds out they're pregnant at the Open Door Women's Health Clinic, they're met with a discussion about options for how — and whether — they want to proceed with their pregnancies.
"We ask them, 'What would you like to do? What's best for you?'" said Humboldt County gynecologist Kim Ervin, whose been providing women's health care in the community for the past 34 years, currently at Open Door Health Clinic. "Then there's the information. We tell them, 'Go back and talk to your families and decide what you want to do, and we can help direct you to the care you need. We have our sister clinic that does obstetrical care, and we have access to procedural and medical termination at Planned Parenthood.'"
Pregnant people always have a choice about whether they want to continue their pregnancy at Open Door and throughout California. Abortion is considered a reproductive freedom that California voters enshrined into the state's constitution in November. In rural Humboldt County, however, abortion access is limited based on pregnancies that have not reached 14 weeks gestation, or 14 weeks from the time of conception.
In an email to the Journal, Planned Parenthood Northern California's Senior Director of Operations Gloria Martinez said, "The Eureka Health Center can accommodate patients needing an abortion up to 13 weeks six days gestation. If a patient is close to this gestation, we do our best to accommodate them as soon as possible. Patients with gestation over 14 weeks are referred to other providers."
Planned Parenthood Eureka offers medication abortion for patients who are at 10 weeks gestation or earlier, and in-clinic abortions — procedural abortions — for those at 10 to 14 weeks gestation. Pregnancies beyond 14 weeks gestation cannot be aborted locally, sending those wishing to terminate them out of the area for treatment. It should be noted that California doesn't allow abortions past a fetus' viability outside the womb, generally considered to be after 24 weeks, unless the pregnant person's life and health are in danger.
Patients seeking an abortion at Planned Parenthood Eureka don't need a referral from a medical provider. If someone takes an at-home pregnancy test and doesn't want to continue the pregnancy, they're able to call (800)-230-7526 or schedule an appointment online at ppnorcal.org.
"Beyond [14 weeks], there's nobody that does that in the community," Ervin said, adding that abortions past 14 weeks are more complicated procedures and there's no one in the county who specialized in the operation. "As long as the pregnancy is in the first trimester, which is the first 13 weeks, and as long you aren't calling at the very last minute, you can get a first-trimester abortion at Planned Parenthood [Eureka]."
First trimesters abortions are by far the most common abortions, accounting for 91 percent of those performed nationally, according to the U.S. Centers for Disease Control.
Second and third trimester abortions are rare, according to the CDC, representing about 7.7 percent and 1.2 percent of abortions, respectively. These types of abortions are more complicated and riskier, Ervin said. According to the Kaiser Family Foundation, abortions are generally only performed this late when there are complications in pregnancy, like fetal anomalies, when a mother's life is endangered due to an illness or when access to first-trimester abortions is limited.
Since Planned Parenthood Eureka only offers first-trimester abortions, women experiencing pregnancy complications or who cannot get an abortion appointment before the 14-week mark have to go out of the area, most commonly to the Bay Area, to seek care, Ervin said.
Planned Parenthood did not answer follow-up questions about where patients are referred, but said the organization's Northern California chapter has a care coordination department and a patient navigator to refer patients to out-of-area providers when needed.
"We ensure the care they need and the location [in which it's provided] are accessible to the patient. We work in partnership with several providers," Martinez said.
Planned Parenthood Northern California is also planning on expanding gestational limits of abortions at its Eureka location to avoid patients having to go elsewhere for care — even though it occurs infrequently, according to Martinez — by offering more evening appointments on weekdays and weekends. As of this month, it is hiring another provider to ensure there are enough appointments available to meet local demand.
"Access is something we monitor closely by looking at Third Next Available Appointment data," Martinez wrote, adding that the software helps Planned Parenthood track how long it takes patients to secure an appointment.
Other Humboldt County clinics and healthcare systems don't offer abortion services because of religious beliefs and federal funding restrictions.
Elective abortions aren't offered at Providence St. Joseph's or Redwood Memorial, the county's largest hospital system, because it's a Catholic institution with the religious belief that life begins at conception. However, in a statement to the Journal, Providence spokesperson Christian Hill said when it comes to complex pregnancies that put someone's life at risk, Providence does not deny emergency care and allows clinicians to "exercise their best medical judgment and provide all necessary interventions to protect and save the life of the mother."
For example, Hill said, the indirect result of treatment for extrauterine pregnancies (also known as ectopic pregnancies, a dangerous and life-threatening condition in which a fetus begins to develop outside of the uterus and occur in 2 percent of pregnancies, according to the American Academy of Family Physicians) is the termination of a pregnancy.
According to Hill, if a particular procedure isn't offered or available at Providence, physicians work with patients to address their needs and discuss all treatment options, including a transition of care to another provider, should it be safe and feasible.
When Ervin first arrived in Humboldt County 20 years ago, all OBGYN services were offered at General Hospital, before it was bought by Providence, so clinicians were able to offer elective abortions with no restrictions at the time.
Open Door, meanwhile, can't offer abortions at all because of the Hyde Amendment.
Congress passed the Hyde Amendment several years after the U.S. Supreme Court ruling in Roe v. Wade deemed abortion a constitutionally protected right in 1976. It prohibits the use of federal funding for abortion services, with the exceptions of pregnancies caused by rape or incest, or when the life of the person carrying the fetus is endangered. As a federally qualified health center — a clinic offering healthcare services to underserved areas with a majority of its funding coming from the federal government — Open Door Community Health can't offer in-house abortion services.
In an email to the Journal, Open Door President Tory Starr said the Hyde Amendment restrictions are quite clear and don't allow for Open Door to offer abortion or termination services of any kind.
The amendment also prohibits Medicaid, a federal assistance program that provides medical health insurance to low-income residents, coverage for abortions, except for cases of rape or incest, or when the life of the pregnant person is endangered. California's Medicaid program Medi-Cal, however, uses state funding to cover the cost of abortions, helping low-income residents in the state who need an abortion to pay for one.
Nearly 84 percent of Planned Parenthood Eureka Health Center patients qualify as low-income (making below 200 percent of the Federal Poverty Level) and 72 percent are enrolled in Medi-Cal, according to the nonprofit.
For people who don't qualify as low-income or aren't enrolled in Medi-Cal, private insurance or don't otherwise have access to subsidized healthcare, the cost of an abortion comes out of pocket.
The University of California at San Francisco operates Advancing New Standards in Reproductive Health (ANSIRH), a leading research program that informs the most pressing debates on abortion and reproductive health, rights and access, and has tracked the out-of-pocket costs of abortions.
ANSIRH runs an Abortion Facility Database which includes information from more than 700 abortion facilities across the U.S. and serves as a tool for the program's research on abortion.
Noting limited data exists on the total out-of-pocket charges for an abortion that isn't covered by insurance, ANSIRH published a study examining the total costs for medication abortions, first-trimester procedural abortions and second-trimester abortions.
Using the Abortion Facility Database's data from 2017 through 2020 for all 50 states and Washington, D.C., ANSIRH found the median patient charges for medication abortion increased from $495 to $560, while first-trimester procedural abortion costs rose from $475 to $575. The median patient charges for second-trimester abortion, however, decreased from $935 to $895.
According to Planned Parenthood's website, medication abortions (pills) can cost up to $800 but average $580 at Planned Parenthood.
An in-clinic abortion during the first trimester can cost up to $800 but average about $600 at Planned Parenthood, according to the nonprofit. The cost of an in-clinic abortion during the second trimester varies depending on a patient's gestation but can run about $715 early in the trimester and later reach $1,500 to $2,000.
"That's the advantage that Planned Parenthood has — that they can provide these services for very low [cost]," Ervin said. "You don't have to pay very much, and they purposely do that so that women can afford the service."
If someone in Humboldt County takes an at-home pregnancy test and chooses not to continue their pregnancy, they will have to make an appointment promptly because of Planned Parenthood Eureka's limitations and its status as the only local provider. But sometimes it's difficult to recognize the early signs of pregnancy if it's not expected.
People who aren't planning on getting pregnant usually aren't looking for pregnancy symptoms, which are very similar to those of an oncoming menstrual cycle, like breast tenderness, fatigue, bloating and mood changes, among others. Ervin said it can also be difficult to detect pregnancy for people with irregular menstrual cycles and for whom skipping a period or two may be normal.
"I think a lot of women don't realize they're pregnant right away. It just depends on what kind of access they have to even get a pregnancy test or what kind of healthcare they have so that someone can actually diagnose them as being pregnant," Ervin said. "For example, OK, you go to the doctor's appointment because you've missed a couple of menstrual cycles but maybe your history is you've skipped cycles on and off and that's normal for you, and then come to find out, well, this time you're actually pregnant and then, woah, it catches you by surprise."
There are several organizations that offer free pregnancy testing to people in Humboldt County, but those organizations are faith-based and focused on giving people alternative options to abortions. Planned Parenthood Eureka offers urine pregnancy testing, but pricing varies depending on insurance.
The Journal calculated the cost of pregnancy tests at various pharmacies in Humboldt County and found the average for a two-pack pregnancy test kit is $14.87, with the cheapest test available at Walmart for 88 cents. Stores like Dollar Tree sometimes also have pregnancy tests in stock for $1.25.
Ervin said that with enough notice, Planned Parenthood is able to schedule abortions to be performed locally but that gets more difficult the closer a pregnancy gets to the 14-week mark.
"Certainly, if you call in when you find out at 12 weeks pregnant, and you didn't know you were pregnant until 12 weeks, then it's going to be a lot harder because you might have to wait a week or two to get into an appointment," Ervin said.
If Ervin has a patient at Open Door with an unexpected pregnancy close to the 12-week mark, she is able to make a personal referral to Planned Parenthood to let them know her patient needs an appointment as soon as possible and, depending on demand, the clinic could be able to reschedule a patient who isn't as far along in their pregnancy to another week. But, again, available appointments depend on the flexibility of Planned Parenthood, its roster of providers and the current local demand for abortion services.
If a Humboldt County resident needs to travel out of the area for an abortion past the 14-week mark but can't afford the traveling costs, there are several national, state and local funding sources available to help.
National and state funding resources can be found at abortionfunds.org. In the U.S., people are able to get help with affording an abortion and other costs through various organizations, including the Indigenous Women Rising Fund, the National Abortion Federation Hotline, The Brigid Alliance and the Women's Reproductive Assistance Project (WRRAP).
In California, organizations like Access Reproductive Justice and the Women's Health Specialist Women in Need Fund are also able to assist people with covering the costs of accessing care. Access Reproductive Justice can be reached at (800) 376-4636 (en Español (888) 442-2237) or at email@example.com. Women's Health Specialist, which operates several clinics in rural eastern California cities like Redding, Chico and Grass Valley, can be contacted at (800) 714-8151.
Locally, the Humboldt Health Foundation, which partners with the Humboldt Area Foundation to improve the health and well-being of the residents and communities of Humboldt County, offers an "Angel Fund" that provides residents needing medical services (including abortion services) outside of Humboldt County, with transportation funding.
Angel Fund grants range from $25 to $300 and are awarded on a one-time basis per person, per 365-day period. A sponsor like a recognized social service agency, school counselor, medical provider or case manager must apply on behalf of the patient to be considered for the grant.
According to Humboldt Health Foundation's website, the sponsor will then help administer the funds, which are not provided directly to the applicant, with the exception of medical travel grants.
Even though Humboldt County is in California, where the constitution protects the right to personal reproductive care, abortion health care services are limited, with only one clinic offering them on a limited basis. It may take some time to see any additional services in abortion care locally, but Ervin said she hopes Open Door Health clinics may one day be able to offer them, broadly expanding local access to its 55,000 patients.
"We're hoping — depending on what happens with the state and perhaps the federal government — that we can provide those medications to our patients, and maybe one day provide the procedure to our patients," Ervin said.
As a reproductive healthcare professional, Ervin deems abortion an "essential" healthcare service, and wants to ensure it is easily available to all Humboldt County residents who need it.
"To me, you're providing a necessary service — it's all about women's lives," she said.
Iridian Casarez (she/her) is a staff writer at the Journal. Reach her at (707) 442-1400, extension 317, or firstname.lastname@example.org.
Editor's note: The story has been updated to accurately reflect Kim Ervin's time as an OBGYN in Humboldt. The Journal regrets the error.