When thinking of abortion access challenges in the United States, waiting periods, mandatory ultrasounds, biased pre-abortion counseling, bans on federal and some state funding, and a dwindling number of independent clinics come to mind. These challenges delay abortion care, increase medical risks, and especially hurt minors. After navigating extreme restrictions and logistical needs to get to the clinic, another problem may arise for some patients: additional fees, which can range from $50-250 (on top of an average cost of $500 for a first trimester abortion), for factors entirely out of the patient’s control, such as having a negative blood type, being over a certain weight, or having a twin pregnancy. Although additional fees are common among various medical procedures, the lack of public and private coverage for abortion costs makes them difficult for some to afford — especially in places where the rate of uninsured people is high.
I have firsthand experience with one: Rhogam. Like 15 percent of the population, I lack the Rhesus factor in my blood, which means I have a negative blood type. If your partner has a positive blood type (or if their blood type is unknown), the fetus can inherit their factor, causing problems with the pregnancy. Pregnant people in this position can be given an injection of rho(D) immune globulin, such as Rhogam, to create antibodies that desensitize our physiological response if our blood comes into contact with the fetus’ blood, should it be Rhesus positive. Without the injection, it could be problematic for not only the health of the pregnant person and developing pregnancy, but the development of future pregnancies. Normally, Rhogam isn’t given during pregnancy until the 28th week, but abortion providers still routinely provide it at earlier gestations.
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I had the privilege of using insurance when I delivered my two children, including one through a cesarean section. Unexpected fees weren’t something I anticipated when I needed an abortion while living uninsured — and I live in Texas, where in 2017 a bill passed prohibiting insurance plans from providing coverage for abortion unless the pregnant person has a separate premium they’ve purchased specifically for abortion. And for most people, Medicaid won’t cover it, either. I learned I’d need to pay $100 because of my blood type, on top of $450 for a surgical abortion. My local abortion fund helped, but it wasn’t enough for me to afford Rhogam and sedation. So I experienced my surgical abortion completely aware, which wasn’t comfortable for me. Nor what I wanted, since medical settings give me anxiety.
Some clinics have taken measures to address the challenges of added fees. And abortion funds, such as the Mississippi Reproductive Freedom Fund, also provide financial assistance. Some abortion providers combine what would typically be additional costs with the price of the abortion, or try to be up front about these fees on their websites. But not everyone has access to the internet, or if they do, it isn’t always easy to find accurate information. Crisis pregnancy centers often use similar names to trick people, who may not realize they’re on a site that isn’t legitimate. So it isn’t unusual for us to learn — for the first time — that we have to pay hundreds of dollars upon visiting the clinic.
“We’ve had patients who choose our clinic specifically because we don’t charge for Rhogam,” one clinic told me. Other clinics may waive the fee for those who need help paying for it, when resources are available to do so. “We received a grant that allowed us to provide our patients with financial assistance for things, and at the time we decided to use it on Rhogam, so people wouldn’t have to miss their appointment over an unexpected thing,” another clinic said. “We recognize the hardship this creates for many people, especially when a lot of people have no idea what their blood type is to begin with.”
The extra cost of Rhogam increased the time one patient needed to pay back a loan they took out on their car in order to afford the procedure. “I had to travel to a different state because it was closer than the clinic where I lived. I had the money from a loan I took out already, but when I found out I’d need to pay $100 more because of my blood type — in addition to the barriers I was already facing — I realized I’d be stuck in this cycle of debt longer than I hoped for,” they said.
I also spoke with Desiree — whose name has been changed to protect her privacy. “I remember standing at the window and being told it would be an extra $100 because of my blood type. It had already taken me weeks to get the $400, and I needed an abortion a few days before rent was due. I had to step aside and really think about what this could mean for my living situation,” she said, since she’d already needed assistance from a local abortion fund.
Laurie Bertram Roberts, co-founder and executive director of the Mississippi Reproductive Freedom Fund, told TalkPoverty: “We hear from many callers that struggle more because of these extra costs. It’s already hard as it is to raise hundreds of dollars for the procedure, especially for our callers who are experiencing homelessness and other barriers related to accessing abortion.”
This issue also affects those who don’t have a negative blood type. “I wasn’t even Rh-negative, but the clinic I went to gives everyone Rhogam,” said another patient. She said the additional cost caused her to drive home on “fumes,” because she had to use her last $50 that was originally intended for gas after driving out of town for her abortion.
When it comes to the extra cost associated with Rhogam, fortunately, things are changing. In Contraception Journal, the National Abortion Federation (NAF) recognized last year that testing for the Rhesus factor in abortion care has become a barrier. They refer to Dutch guidelines, which say the injection is unnecessary for pregnancies less than eight weeks — and Sweden also recommends against the injection for early medical abortion.
NAF recently updated its recommendations regarding when Rhogam is required. They no longer recommend it for early abortions less than eight weeks, most of which are medical abortions and account for two thirds of the abortions performed in the U.S., according to the Guttmacher Institute. Now, people with a negative blood type — who find out about their pregnancy early on — may have the ability to forego Rhogam at NAF-member clinics. Some experts say it isn’t necessary for a first pregnancy at all.
Dr. Alice Mark, NAF’s Medical Director, told TalkPoverty: “We know giving the Rhogam injection at 28 weeks decreases the risk of sensitization, but what we don’t know is that any intervention before that has any impact on the outcomes…The studies [on sensitization] use methods that are outdated, and we were doing this intervention without knowing whether or not it benefited patients.” They drew heavily on data from Europe, where not providing Rhogam early in gestation has “no appreciable impact.”
Dr. Mark stressed that some clinics may want to follow American Congress of Obstetricians and Gynecologists (ACOG) recommendations to protect their patients, and that’s not wrong. “But because we’ve made this change, it’s been taken to ACOG to be discussed on their committees,” said Dr. Mark.
One clinic I spoke with told TalkPoverty that, “We’re going to follow the [NAF] recommendations, and we should be updating the guidelines in the next month. All of our physicians are really excited to follow these guidelines — there’s a lot of research on it. It’s an extra barrier for patients.” Patients are also growing more aware. “I didn’t need it because I’m less than eight weeks,” said one person I spoke with before her abortion.
This isn’t the fault of clinics. It is the result of the systemic issues related to extreme abortion restrictions. After all, paying for abortion could be a lot easier if there wasn’t a federal ban on public funding. Independent clinics perform the majority of abortions in the U.S., but they receive absolutely no support from our government. Use of state dollars for Medicaid reimbursements for abortions is highly restricted in Texas and a number of other states, so while some providers may combine these additional fees in the cost of the abortion, it’s inevitable not all would be able to in order to sustain the operation of the clinic. In eleven states, including Texas, most people can’t use their private health insurance for their abortion, either.
And with providers across the country facing closures due to medically unnecessary restrictions, accessing a clinic becomes less of a reality for many even without these additional costs. Next month, Missouri will give a final ruling in the case of the state’s only abortion provider shutting down. Six states currently have only one clinic, and Missouri could be the first with zero. In Texas, we have the most cities more than 100 miles away from an abortion clinic. For some of us, there is no choice: we’re forced to continue a pregnancy we don’t feel ready for.
Because even though we have a legal right to have an abortion, lawmakers continue to remind us that our right to choose means nothing if we can’t access it.