When patients came to Kelly Nichols, a nurse practitioner at a clinic in Newark, Delaware, needing care for their miscarriages, Nichols often prescribed medications to help with the process.
But if patients came to Nichols seeking to end a pregnancy, she was not able to prescribe them the exact same medications.
“It was just purely a political block on it,” Nichols said, that had nothing to do with health or safety – medication abortions, which now account for the majority of abortions in the US, have been shown to be very safe.
Instead, her patients seeking medication abortion need to schedule a second appointment with a state-certified physician at a different facility, a time-consuming and sometimes arduous process, especially for those who weren’t able to take more time off from work or travel to a different facility.
But all of that is now changing. A new law allows physician assistants and advanced practice registered nurses, who are already able to prescribe many medications, to prescribe the medication for abortions as well. Democratic governor John Carney signed the legislation into law last week.
The law will increase the number of providers in Delaware and make the process of getting an abortion less complicated. Medication abortion, also known as the abortion pill, can be used safely up to 10 weeks into a pregnancy.
The new law is one of several ways abortion and other forms of reproductive health care are becoming more accessible in Delaware, even as restrictions and bans loom in other states across the country.
Known as the First State for being the first to ratify the US constitution, Delaware was also the first in the wake of Trump’s election to codify Roe into state law in 2017, protecting the right to abortion even if the landmark supreme court decision is overturned.
The 2017 law ensures access to abortion until viability, defined at 20 weeks of pregnancy in Delaware. Procedures are also permitted later if the patient’s life or health is threatened or if there’s a serious fetal anomaly.
Codifying abortion protections into state law “really is the strongest protection that a state could give,” said John Culhane, professor of law at Widener University Delaware Law School.
And on 1 December, the same day the court heard arguments on the 15-week abortion ban in Mississippi that could overturn Roe, the first Planned Parenthood clinic in a decade opened in Delaware’s most rural county.
Delaware is one of several blue states introducing new laws and planning to increase services as the constitutional right to abortion in the US looks to be in peril. Other states looking to expand access include Vermont, New York, California and Maryland. Washington and Connecticut have also passed laws to extend protections to providers aiding in the abortions of people who travel from out of state.
With the overturn of Roe, about 16 states will be able to continue providing abortion services without restriction or with minor restrictions, said Ruth Lytle-Barnaby, president and CEO of Planned Parenthood of Delaware, which runs the clinic where Nichols works.
“Those of us that are left are going to have to absolutely gear up to be able to see a lot more people,” she said. The new law on medication prescription “opens up more access for more patients, because we will be able to expand the number of providers providing this care.”
The Delaware expansions are not without opposition. Although the state reliably goes blue, the southern part is more rural and conservative.
News of the new clinic in the southern town of Seaford, for instance, was greeted with protests and local restrictions before it even opened.
Seaford, which describes itself as a “traditional” community, is an industrial town home to less than 8,000 people. It’s nestled in the most rural part of the state, where chickens tend to outnumber people – and Trump signs still hang, even in the state Joe Biden represented in Congress for decades.
Up north, the populous New Castle county always goes deep blue, pulling the rest of the state with it. But here in Sussex county, the political map is red, and residents tend to hold more conservative views.
In December, after news of the new clinic, the Seaford city council passed an ordinance requiring fetal tissue from miscarriage or abortion to be buried or cremated, a cost to be borne by patients or providers.
According to Delaware law, however, fetal tissue prior to 20 weeks of gestation is not considered human remains, and a death certificate – which is required for cremation or burial – is not issued.
In January, the state’s justice department took the unusual step of suing the city because of the ordinance’s conflicts with state legislation on handling fetal tissue. It would have also added prohibitive costs, opponents say.
For now, this ordinance is blocked, and the Seaford clinic opened without the restrictions.
Delaware’s intrastate struggles are “a microcosm of the sorts of things we can expect to see in states that continue to allow abortion access, where there’s resistance to that in certain localities”, Culhane said.
Every year, Delaware state legislators introduce at least one bill to restrict reproductive health, Lytle-Barnaby said. “Even in the progressive states, we have to re-litigate this every single year.”
And even in states that do not have restrictive laws on abortion, there are limits on receiving care. There may be areas with no providers for miles around, and it can be difficult for some patients to book appointments and take off work to travel within or outside the state.
“Delaware has three counties, and they’re all classified as medically underserved,” said Lytle-Barnaby. The average wait time for any patient to see a new doctor is 28 days for Sussex county and 32 days for Kent county, she said.
Sussex county is also growing the fastest, with a 23% increase in the past decade, Lytle-Barnaby said – and at the same time, the county has the highest rates of uninsurance and child poverty in the state.
The last clinic in Sussex county, located in Rehoboth Beach, closed in 2011, and the clinic in nearby Salisbury closed in 2015.
The location in Seaford was chosen, in part, to be more accessible to patients from outside the state as well, since those areas also have poor access to care and high poverty rates.
Delaware is taking other steps to strengthen reproductive health. A program on contraceptives has proven a model for other states to reduce unintended pregnancies.
Long-term contraceptives, like IUDs and implants, are very effective at preventing pregnancies. But it can be difficult to find providers who offer this type of birth control, and some people may not know they even exist.
DelCAN, which started in 2014, helps smooth the process – training providers and making these forms of contraception easy to access and covered by insurance.
Medical providers ask a simple question at health visits: “Do you want to get pregnant in the next year?”
If the answer is yes, they talk about prenatal vitamins and health care. If it’s no, they talk about “set it and forget it” contraceptives that are more effective than methods like the pill or condoms.
When it started, Delaware had one of the highest rates of unintended pregnancies in the nation, but that rate fell by 20% – twice as much as other states – after the introduction of the program.
Abortions in Delaware also declined by 37% between 2014 and 2017, according to a Guttmacher report.
States can go even further to shore up abortion rights. Delaware, for instance, still requires parental notification for patients under 16, and public funds like Medicaid can’t cover abortion except in the cases of rape, incest or danger to the patient’s life.
“There are some states where Medicaid funds abortion – it’s a health service,” Lytle-Barnaby said.
Expanding Medicaid to cover abortion would also help people living in poverty, Culhane said, “because a lot of the burden of these laws is going to fall on poor women”.
A bill in Oregon, introduced in the wake of neighboring Idaho’s proposed restrictions, would provide $15min funding for abortion services, including for out-of-state patients.
States can also pass laws protecting providers if patients travel from states where abortions are banned, as Washington and Connecticut have done. Such protections may be necessary given the likelihood of states seeking to crack down on out-of-state travel for abortions, Lytle-Barnaby and Culhane said.
But amid all the politics, the health care Nichols provides is straightforward. The law now allowing her to prescribe medications for abortion will make the care she offers easier and more accessible to patients.
“Management of other pregnancy complications is really pretty much using the same exact skill set and knowledge and medications as provision of medication abortion,” she said. “So it really just makes sense – it makes sense to be able to provide a continuity of care for the patients.”