Maryland is one of the few places in the United States serving people who need later abortions, home to two of the only clinics in the country that perform procedures into the third trimester.
These clinics are becoming increasingly critical as abortion bans in other states make it harder to get the procedure earlier in pregnancy.
In Maryland, after viability, which is usually between 22 and 24 weeks, qualified providers approve patients for an abortion in certain rare cases, typically based on fetal abnormalities or health risks for the pregnant person.
Since the Supreme Court's Dobbs v. Jackson Women's Health Organization decision overturned Roe v. Wade in 2022, Maryland providers have seen an influx of out-of-state patients, including an increasing number needing later abortions.
Data from the National Abortion Hotline shows that in 2022, the overwhelming majority of callers traveling to Maryland to get abortions were in their first trimester. That ratio has shifted since the Dobbs decision - by July 2024, more callers were at least 20 weeks pregnant.
"One of the things we hear most frequently [from patients] is 'we never thought we would be in this position, but we're so glad you're here,' " an abortion provider at CARE (Clinics for Abortion and Reproductive Excellence) Bethesda told Capital News Service. She asked to remain anonymous due to safety concerns.
When Partners in Abortion Care opened in College Park in October 2022, it joined CARE Bethesda as the second clinic providing all-trimester procedures, roughly doubling later abortion appointment availability in the state. Each clinic performed more than 400 abortions at 21 weeks or more in 2023. However, providers say demand outpaces capacity.
The clinics perform abortions until 34 weeks and 35 weeks and six days, respectively.
Centers for Disease Control and Prevention data shows later abortions are rare - 93% occurred in the first trimester in 2022, the last year with available data. Less than 5,000 abortions, or about 1%, occurred after 21 weeks.
Morgan Nuzzo, a certified nurse-midwife and co-founder of Partners in Abortion Care, said there are two pathways to someone needing a later abortion - either "the person learns new information," like a fetal or maternal health diagnosis, "or they experience barriers to care," she said.
President and CEO of the National Abortion Federation Brittany Fonteno said in rare cases, people, often minors, don't discover they're pregnant until after 20 weeks - 22 states ban abortion at 20 weeks or less.
The CARE Bethesda provider said that patients with a fetal anomaly diagnosis may delay an abortion for further testing.
"Individuals so desperately are wanting and hoping that those genetic tests were wrong," she said. "That also bumps back the date because they're hoping that there was a mistake made, but then they're still left with the same reality."
Barriers that delay care can include state bans, lack of funds and travel logistics.
Some patients experience domestic violence or homelessness, making caring for a child emotionally or financially devastating.
"In my experience, the biggest misconception is that at any gestation, this is something that is done lightly," the CARE Bethesda provider said.
Providers and advocates say bans meant to stop abortion push some patients later in pregnancy, increasing costs for patients and clinics.
"This is what nobody wants to talk about - people who tried to get abortion earlier in their pregnancy but were forced to wait," Fonteno said.
If patients can't scrape together the funds in time, they often have to reschedule their appointment, leading to rising costs as appointment prices increase based on the stage of the pregnancy.
April Greene, interim executive director of the Blue Ridge Abortion Fund in Virginia, said this creates a vicious cycle of rising costs.
"We're definitely seeing people further along than we used to, and we're seeing people whose clinic costs are more expensive," Greene said.
Third-trimester procedures often cost between $10,000 and $20,000. Hotel stays, flights, time off work for the multi-day procedure and childcare also add up, Greene said.
The fund largely supports people getting abortions in Virginia, but it helped support 163 people traveling to Maryland since the Dobbs decision, mostly for later abortions, Greene said.
As abortion gets more expensive, funds and clinics struggle to meet demand.
In July 2024, the National Abortion Federation cut direct support to patients and clinics, covering 30% of total abortion costs for qualified patients instead of 50%.
While the organization's budget increased in 2024, "the demand still wildly outpaces the resources," said Fonteno.
The funding cuts hit Partners in Abortion Care hard -- the clinic almost closed this fall.
The clinic's budget is particularly vulnerable because it's the only Maryland clinic that accepts Medicaid for later abortions. If patients have Medicaid, they pay nothing for the appointments, but Maryland only pays back a portion of the cost to Partners.
"We are losing money on every later abortion service we provide for Medicaid patients," co-founder Nuzzo said. "But it is the correct thing to do."
If Partners closed, it would have sweeping effects for low-income patients needing later abortions across the country.
Abortion restrictions disproportionately affect people of color, low-income people, young people, LGBTQ+ and immigrant communities, Fonteno said.
"At the end of the day, your ability to control your own body really determines your trajectory in life," Fonteno said.