“Rural women, women of color, low-income women will be disproportionately affected the closure of the clinic,” said Margaret Chapman Pomponio, executive director of WV FREE. “It means that getting by day-to-day for marginalized women just got harder in West Virginia.”

Families in Appalachia, a mountainous region that extends from northern Georgia through western Pennsylvania, often face significant obstacles to accessing basic reproductive health care.

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When the Kanawha Surgicenter in Charleston closed on January 17, the Women’s Health Center in Charleston was left as the only abortion clinic in West Virginia.

A week later, the EMW Women’s Clinic in Lexington closed, leaving the EMW Women’s Surgical Center in Louisville as Kentucky’s last abortion clinic.

Families in Appalachia, a mountainous region that extends from northern Georgia through western Pennsylvania, often face significant obstacles to accessing basic reproductive health care. The closing of these clinics will only increase the difficulty in accessing health services for those in a region plagued by generations of deep poverty.

The executive director of EMW in Lexington said in a statement that it was with “extreme sadness and deep regret” that the Lexington clinic would close. The statement, published on January 13 by the Kentucky National Organization for Women, said the organization had “diligently pursued obtaining a license” for the facility, but after a lengthy legal battle, was not able to secure the license.

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“Although we and our attorney believed we had fulfilled all the requirements to obtain the license, the Inspector General of [Kentucky] disagreed and denied us the license,” the executive director said. “Unfortunately, our landlord has also declined to renew our lease on the space we have occupied … since 1989.”

EMW does not publicly identify employees to maintain privacy.

Dr. Gorli Harish left a note on the front door of the Kanawha Surgicenter informing clients that the clinic would be closing, reported the Charleston Gazette-Mail. The clinic’s phone has since been disconnected, and its website has been taken down.

Kentucky and West Virginia join Missouri, Mississippi, North Dakota, and South Dakota as states that have one abortion clinic as reproductive rights come under persistent attack by federal and state Republican lawmakers.

The GOP’s lengthy anti-abortion campaign has led to a dramatic number of abortion clinic closures. At least 162 clinics that provided abortion services have either closed or stopped offering the procedure since 2011, with 21 clinics opening during that time, according to a report by Bloomberg.

Abortion clinic closures have a disproportionate affect on people living in rural areas, those with low incomes, and people of color.

Vicki Saporta, president and CEO of the National Abortion Federation, told the Huffington Post that while most urban areas still have “reasonable access to abortion care,” rural areas often lack adequate access to the medical procedure.

“The problem lies when women are in more rural areas, or some of these states where there are only one or two providers,” Saporta said.

In 2014, prior to the closure of the Lexington abortion clinic, 74 percent of Kentucky women between the ages of 15 and 44 lived in a county without a clinic. Also during that time, 90 percent of West Virginia women between the ages of 15 and 44 resided in a county without a clinic, according data from the Guttmacher Institute.

“It Means That Getting By Day-to-Day For Marginalized Women Just Got Harder in West Virginia.”

Margaret Chapman Pomponio, executive director of WV FREE, told Rewire that West Virginia’s large rural population and high rate of poverty already make it difficult for families seeking reproductive health care.

West Virginia has one of the country’s highest poverty rates, with 18 percent of the state’s residents living in poverty compared to 14.7 percent nationally, according to 2015 statistics compiled by the U.S. Department of Agriculture Economic Research Service (ERS).

“Rural women, women of color, low-income women will be disproportionately affected the closure of the clinic,” Chapman Pomponio said. “It means that getting by day-to-day for marginalized women just got harder in West Virginia.”

Marcie Crim, executive director of the Kentucky Health Justice Network, said in an email to Rewire that having only one abortion clinic in the state poses significant challenges to people seeking abortion care—particularly in the state’s rural areas.

Kentucky’s poverty rate, at 18.3 percent, is higher than West Virginia’s, according to 2015 statistics compiled by ERS.

Since the Lexington clinic closed, Kentucky Health Justice Network has seen an increase in the number of transportation requests to the Louisville clinic, particularly from people living in Lexington and the eastern and southern portions of the state.

“Many low-income people don’t have the money or the car to get themselves to Louisville,” Crim said. “Many people don’t have a support system to help get them to their appointments or they don’t feel safe telling friends and family, so adding extra driving hours—extra obstacles—leaves folks in very difficult situations.”

Those in eastern Kentucky and southern West Virginia, who now have to travel farther for abortion care, live in counties with crushing poverty.

Clay County, Kentucky, has the third highest poverty rate in the United States, according to the U.S. Census Bureau. The county has some of the worst health outcomes of any county in the country. A resident of Clay County would now have to travel 170 miles to access abortion care in Louisville or travel 200 miles to access abortion care in Charleston.

A resident of McDowell County, West Virginia, would have to travel about 100 miles to Charleston to receive abortion care. However, even when the distance is shorter, challenges remain.

“Charleston is like a world away for a woman living in McDowell County for example,” Chapman Pomponio said. “Traveling out of state for abortion care is probably insurmountable.”

McDowell County, the poorest county in the state, is emblematic of the systemic poverty that has lingered in Appalachia for more than half a century. During 2014, when West Virginia had the highest number of drug overdose deaths in the country, McDowell County had the highest number of drug overdose deaths in the state.

The Affordable Care Act (ACA) had a dramatic effect on decreasing the number of people without health insurance nationwide, and from 2013 to 2015 the percentage of residents in Kentucky and West Virginia without insurance was cut in half, according to Gallup.

Despite President Trump’s promise to repeal the ACA, known as Obamacare, residents of both Clay and McDowell counties overwhelmingly voted for him in November. Trump won 87 percent of the vote in Clay County and 75 percent of the vote in McDowell County.

‘Preventing Access to Safe, Legal Abortions Doesn’t Prevent Abortions’

When Republicans swept into power in state legislatures behind 2010’s Tea Party fervor, the new GOP majorities quickly set to work passing medically unnecessary laws designed to erode abortion care access.

The GOP takeover of West Virginia and Kentucky wasn’t completed until years later. Republicans would not gain control of the West Virginia legislature until the 2014 midterm elections. GOP legislators took over the Kentucky legislature in 2016.

Republican lawmakers in Kentucky and West Virginia have used these new majorities to push through several anti-choice measures, creating additional barriers to abortion besides the miles that must be traveled.

West Virginia’s former Gov. Earl Ray Tomblin (D) in 2016 vetoed a ban on abortion care after 20 weeks of pregnancy and a measure outlawing the most common method of second trimester abortion. Lawmakers in the legislature voted to override Tomblin’s vetoes.

When the Kentucky legislative session began on January 3, the new GOP majority fast-tracked legislation that would restrict access to abortion care.

Kentucky Gov. Matt Bevin (R) signed a pair of anti-choice bills, which banned abortions after 20 weeks of pregnancy and required an ultrasound prior to an abortion procedure. Bevin last year signed a law requiring state-mandated counseling prior to an abortion procedure.

“It can be as much as a five hour drive from parts of eastern Kentucky to Louisville and with the ‘informed consent’ law requiring 24 hours between the provider consultation and the procedure, that is extra challenging,” Crim said.

When women are able to travel to Louisville for abortion services, they must endure the constant presence of anti-choice protesters in front of the clinic. Volunteers escort patients past the protesters into the clinic.

Fausta Luchini, a volunteer escort at the Louisville clinic, told WAVE 3 that abortion clinic closures don’t stop people from having the procedure. “Women have been having abortions forever,” Luchini said. “It’s not like [closing] the clinics is going to keep them from having abortions, they just won’t be safe abortions.”

Joseph Spurgeon, leader of the anti-choice clinic protest group P82 Ministries, told WAVE 3 that he wants the last clinic in the state to shutter. “We are glad this is the last clinic,” Spurgeon said. “But we will be even happier when this place is paved over and there is a sign that says they used to murder babies here.”

Crim said it would be catastrophic if the Louisville clinic were to close.

“The most devastating impact would be folks attempting to self abort or getting unsafe abortions,” Crim said. “History has taught us that when safe, legal abortion access is severely limited, women seek out other methods to terminate pregnancies.”

Texas Republicans’ omnibus anti-choice law known as HB 2 forced more than half of the state’s abortion clinics to close. Reproductive rights advocates said that they started seeing signs of people taking matters into their own hands almost immediately after Republican lawmakers pushed through the law. A study by the Texas Policy Evaluation Project (TxPEP) found that between 100,000 and 240,000 Texas women of reproductive age have attempted to end a pregnancy without medical assistance.

“Preventing access to safe, legal abortions doesn’t prevent abortions,” Crim said.”It just prevents safe abortions.”