When Anna found out she was pregnant in October, she knew she could not have another child. Her son was still a baby and she was struggling to find employment as a 30-year-old single mother in East Chicago, Indiana, where she lives.

So Anna went to the Planned Parenthood clinic in her town, looking to have an abortion. (Because of concerns about privacy, she asked to be identified by a pseudonym.) But she was 13 weeks pregnant, and Indiana requires abortions after the first trimester to be performed in a hospital or licensed surgical center. For women whose pregnancies do not pose serious health risks, this can make a second-trimester procedure difficult to access, as well as prohibitively expensive. A counselor at Planned Parenthood suggested Anna travel to a clinic in Illinois for the procedure, where the regulations around second-trimester abortion are less stringent.

Thousands of Indiana women have gone to neighboring states seeking abortions in the past four years as Republican Gov. Mike Pence and anti-abortion legislators pushed the state to adopt abortion laws that are among the most restrictive in the nation. For some of these women, taking the considerable time and expense required to go out of state to end their pregnancies was a better prospect than navigating Indiana’s web of restrictions.

Anna took the Planned Parenthood counselor’s advice, started to cobble together as much as she could, $300, for the procedure, and made an appointment at one of the three Family Planning Associates clinics in Chicago. “If I wanted the situation taken care of, then going to Illinois was what I had to do, so I called the clinic and said my pregnancy test was positive and I needed help,” she said.

Since 2011, Indiana has systematically passed laws that erode access to abortion and other reproductive health services. It was the first state to pass a law mandating the burial and cremation of fetal tissue and to prohibit abortion due to fetal anomalies. The state also charged two low-income women of color — Bei Bei Shuai and Purvi Patel — with “feticide” and sent them to jail, creating a dangerous precedent of criminalizing women who attempt to end their pregnancies. During his four years as governor, Pence, a self-described Christian conservative, signed every one of the eight abortion bills that crossed his desk and slashed funding for Planned Parenthood. These measures have caused half of the state’s clinics to close over the past five years and placed heavy restrictions on the six clinics that remain open. Just four out of 92 counties in Indiana have an abortion clinic, meaning a majority of women seeking abortions must travel long distances, on multiple occasions, to make their appointments.

Mike Pence signed every one of the eight abortion bills that crossed his desk and slashed funding for Planned Parenthood.

Now that Pence is joining Donald Trump in the White House in January, the barriers to abortion access women face in Indiana could become the future of reproductive rights nationwide. At a summer campaign event in Michigan, Pence promised the crowd that the Trump-Pence administration would consign Roe v. Wade “to the ash heap of history, where it belongs.” Indiana’s are among 231 new abortion restrictions states have adopted since the 2010 midterm elections, and state legislatures are already pursuing laws that would effectively ban abortion in their states. On Nov. 17, Indiana State Rep. Curt Nisly announced his plan to introduce a total abortion ban, and earlier this week Ohio lawmakers passed a “heartbeat bill” that would ban abortions after a fetal heartbeat can be detected, which is usually around six weeks.

In a recent interview with CBS’ “60 Minutes,” Trump himself said he supports abortion rights going back to the states. When the interviewer suggested women in anti-abortion states then wouldn’t be able to get the procedure, Trump responded: “Yeah, well, they’ll perhaps have to go, they’ll have to go to another state.” He also suggested in March that women who have abortions, if the procedure is made illegal, should undergo “some form of punishment.”

The Supreme Court has already determined that crossing state lines to obtain an abortion constitutes an “undue burden” on women, and so-called TRAP laws restricting abortion access in states around the country, including some of the most extreme laws in Indiana, are now tied up in litigation. However, with Trump poised to fill the court’s vacant seat (with the potential to fill more) and with Pence governing by his side, reproductive rights are at serious risk — particularly for women who already face barriers to health care because of their income, race, location, age, religion, or immigration status.

“Since Pence has taken office as governor in Indiana, we have seen him sign restriction after restriction for access to reproductive health care,” said Amanda Allen, a lawyer with the Center for Reproductive Rights. “He has chipped away and away and away until the right to abortion becomes a reality on paper but not in practice. Pence’s vision for women, for families, and for anyone who doesn’t fit into his worldview is frightening. He poses a grave threat to women’s health.”

The abortion rate in Indiana has dropped precipitously since 2010, faster than national averages. In 2015, 7,957 women had abortions in the state. Abortion opponents argue the nationwide decline is a result of changing attitudes about abortion, while advocates attribute it to greater access to affordable contraception. In Indiana, however, the drop is also because these burdensome restrictions and lack of access to care are driving thousands of women to travel out of state for basic health care.

“Every single day I operate, I see someone from Indiana — including 25 percent of my patients today,” Allison Cowett, an OB/GYN and the associate medical director at Family Planning Associates, told me last month. “I ask them, ‘Why are you here?’ and the main thing they say is that it’s just too cumbersome to do the process in Indiana. There they’d have to take more than one day off work, so it makes more sense to drive the extra hours, spend a few hours at the clinic here, and then drive back. They just want the process to be complete.”

For women who are able to access abortion care in Indiana, the state’s laws add unnecessary stress and strain to the experience.

When Emily O’Brien was 19, she needed an abortion. This was four years ago, when the Planned Parenthood in her hometown of Richmond was still open but not authorized to perform abortions. Indiana requires all women seeking abortions to undergo private, in-person, state-directed counseling and then wait 18 hours before they can have the procedure. O’Brien was able to receive the counseling in Richmond before traveling to Indianapolis for the procedure itself. The Richmond location has since closed, along with six other Planned Parenthood health centers in the state (four others have consolidated).

Even though O’Brien did not have to cross state lines to have her abortion, the process wasn’t any easier, nor the experience any better. She still had to miss multiple days of work and school.

Experiencing firsthand how challenging it was to access abortion care, O’Brien decided to get involved with reproductive rights activism. Today, she serves as the vice president of the Indiana chapter of the National Organization for Women.

“I had to go through the counseling, which has no medical purpose whatsoever other than to try and dissuade women from getting abortions,” O’Brien said. “The people at Planned Parenthood were apologetic about the things they had to say, but it was still traumatic. The language in the counseling is intentionally designed to make you feel guilty. It’s basically just, ‘Let’s ask if you’re sure about this as many times and as many different ways as we can.’”

After her initial appointment, O’Brien waited two days for the procedure then drove to Indianapolis the night before and stayed in a hotel so she could be at the clinic at 8 a.m. Upon arrival, she had to walk a gauntlet of hostile anti-abortion protesters as she entered the facility, and later the same thing when she exited. She spent the entire day at the clinic, waiting around, having the required ultrasound, and going through yet another round of so-called informed consent counseling.

“There is no way they can physically make women turn their heads and look at the ultrasound, but the law on the books says they have to ask if you want to see it,” O’Brien said. “It’s another cost and another mental game. I was only eight weeks pregnant. Then I had to do a second round of counseling, which included watching these terrible videos of women who said they had an abortion and regretted it.”

After hours of waiting and counseling, O’Brien was given the first pill of the medication abortion protocol in the doctor’s office and told to take the second pill at home.

“That was it,” she said. “It was the easiest procedure with the least amount of danger, and yet, they make it as difficult as you could imagine to obtain, literally, two pills.”

O’Brien said she was fortunate to have a savings account, which she drained to afford those two pills. Abortion care in Indiana is covered under insurance policies only in the case of rape, incest, or if a woman’s life or health is in serious danger, which means most women have to pay out of pocket. Given the hulking barriers, the tangle of restrictions, and the pervasive hostility, traveling out of state is often the more convenient, and sometimes only, option.

Illinois is commonly described as a “donut hole” in the Midwest, where abortion care can be delivered without the smog of onerous restrictions. Nearby states — Indiana, Wisconsin, Missouri, Ohio — also have gone after reproductive rights with intensive regulation. Ohio, under the leadership of Gov. John Kasich, has adopted anti-abortion legislation at a rate similar to Indiana and caused more than half the clinics there to close. As a result, Illinois, and to a lesser extent Michigan, has become a magnet for women in the Midwest seeking reproductive health care.

About 3,000 abortions a year in Illinois are provided to out-of-state residents, according to the Illinois Department of Public Health. Last year, Planned Parenthood of Illinois saw a 20 percent spike in medical visits overall, with Indiana sending more patients than any other state. Not all these visits by Indiana women were for abortions, but the share that were rose to 57 percent through June of this year, compared to 44 percent the year before.

Michigan has also seen an uptick in abortions driven by women coming from nearby states. Its abortion rate increased 18 percent from 2010 to 2013, and the number of non-residents getting abortions in the state reportedly doubled from 2014 to 2015. In the 2013-2015 period, Planned Parenthood of Michigan experienced a 48 percent increase over 2011-2013 in the number of patients coming from Indiana for abortion services. Limiting abortion access does not mean women stop getting abortions; it means those who can are going elsewhere to get them.

Limiting abortion access does not mean women stop getting abortions — it means those who can are going elsewhere to get them.

When there are only a few places where women can access reproductive health care, remaining clinics can become flooded with demand. That’s what happened in Texas after a law there caused half the clinics in the state to close. Women had to wait longer to make appointments and to be seen for their appointments once they arrived at the clinic. Waiting rooms overflowed.

Clinics in Illinois and Michigan say they are currently able to handle the increased volume of out-of-state visitors through measures like extending their operating hours, but this might not be sustainable if more clinics in surrounding states close. And beyond providing actual appointments, it can be the social needs of their patients — transportation, money, child care, time off — that are more difficult for organizations like Family Planning Associates to handle and for patients to overcome.

“This is the way it was before Roe v. Wade,” Cowett, the clinic OB/GYN, said, referencing the landmark 1973 Supreme Court decision guaranteeing women’s right to abortion. “If you were a white upper-middle-class person, you could drive to New York to get your abortion. It works similarly in states with more burdens and restrictions. If you don’t have the capacity to travel because of your economic status, then you can’t access the services that you need.”

For many women, traveling a few extra hours can represent a significant challenge. It’s not as simple as picking up and going. Even a drive of 30 minutes can pose obstacles that can’t be surmounted without help, especially when some women are saving every penny they have just to afford the procedure.

Anna tried to save money for her abortion, and her mother pitched in, but the farther along a pregnancy is, the more expensive it is to end. While a first-trimester abortion averages around $500, second-trimester abortions can cost thousands of dollars, creating a race for women to raise as much as they can, as quickly as they can, before they reach 20 weeks, when Indiana bans abortion except in cases where the woman’s life or physical health is in danger.

“I told the clinic I had financial problems, that I didn’t have any income and needed assistance,” Anna said. “They said they could help me with the remainder of my balance for the procedure, but I was also worrying about getting back and forth because I don’t have a car, or about having a place to stay, since it’s a two-day procedure.”

Family Planning Associates put Anna in touch with the Midwest Access Coalition, a grassroots organization that provides accommodation, transportation, and practical support to people traveling to Chicago for abortion care. Second-trimester procedures typically happen over a two-day period, and MAC helped Anna pay for cabs to and from her house to make the early-morning appointments and train tickets back home in the afternoon.

Leah Greenblum founded the organization in 2014 specifically to address the unmet needs of women flooding into Chicago to have abortions, particularly those from neighboring states. MAC volunteers provide assistance with just about anything — a safe place to stay in their own homes, meals, help paying for medication, gas money, bus tickets, and taxi fares — since it’s not uncommon for a woman to show up with the amount needed for the procedure in her pocket and nothing more.

“People are so worried about scraping together the money for the procedure that they don’t think about incidental costs, like how to get there and where to stay,“ Greenblum said. “We had a teenager come to Chicago from Indiana with just $20 in her pocket for the entire three days she was going to be here. That was not even going to cover the cost of the prescription she needed. $20 gets you like one sandwich in Chicago.”

It’s not uncommon for a woman to show up with the amount needed for the procedure in her pocket and nothing more.

The burden of traveling out of state is much heavier for low-income women, who often resort to desperate measures to make the journey. Cowett said she once saw a patient who was planning to sleep in her car overnight in the dead of the Chicago winter. Procuring transportation, accommodations, and childcare (a majority of women having abortions already have one child) can be impracticable without outside help.

“I had to get childcare for my son and I needed to make sure I was there on time in the morning,” Anna said. “I also don’t have a car or someone, like a family friend, who could pick me up. It would have been better if I could go closer to my home in Indiana instead of spending hours traveling, but I had help from the clinic and the MAC, and so everything worked out.”

Not everyone is able to access that much help. They may not be aware that these types of programs exist, or the available money is not enough to address all their needs. Or they may face hurdles beyond finances. Women who live in communities that shun abortion or who are in abusive relationships often need to keep their procedures a secret for their own safety, and while they may be able to slip away for a day, a multiday trip, not to mention a significant outlay of money, may be impossible to coordinate without anyone finding out.

To date, MAC has helped 79 people, most of whom come from out of state. Greenblum said every call she answers requires creative problem-solving to assess the caller’s unique needs and figure out how to meet them.

“People are coming here with so little money and they are afraid they won’t be able to come up with as much as they said they could for the procedure,” Greenblum said. “When they call us, I am racking my brain, thinking about how to get them from middle-of-nowhere Indiana to Chicago, and they are taking a leap of faith and talking to some stranger on the phone who is supposedly going to help them. It’s desperation. They have no other choice.”