When Sean Brown opened an urgent care clinic in a remote town in Michigan’s Upper Peninsula, he never thought about performing abortions.
But she never expected Marquette’s family planning organization to close last spring. Approximately 1,100 patients used the clinic each year for cancer tests, IUD insertions, and medical abortions. There are currently no other in-person resources for abortions in the area. “It’s cordoned off for 500 miles,” Brown said.
So the doctor, who calls herself “personally pro-life,” added medication abortions to her already busy practice at Marquette Medical Urgent Care, which treats a steady stream of children with the flu, college students with migraines, and tourists injured while skiing.
At least 38 abortion clinics closed last year in states where abortion is still legal, according to data collected by I Need an A, a project supported by many nonprofit organizations to help people find abortion options. Even states that recently passed constitutional amendments protecting abortion rights, such as Michigan, have closed clinics since the U.S. Supreme Court reversal. Roe vs. Wade And as local hospitals close their labor and delivery departments, patients are losing access to pregnancy care. “You can’t have a high-risk pregnancy here,” Brown says. “It’s a scary place.”
Now, the community is coming up with alternatives, including emergency care for Brown.
The idea that emergency medicine “could be an untapped solution to the closure of abortion clinics across the country” is very exciting,” said Kimi Chernoby, chief operating and legal officer at FemInEM, a national nonprofit organization dedicated to improving the professional training of women in emergency medicine and patient outcomes.
One of the patients who recently received emergency treatment at Marquette was a woman, who KFF Health News agreed to identify only by her first initial, “A,” to protect her medical privacy. She drove more than an hour down snowy back roads to her appointment while her children were at daycare.
Ms. A said her youngest child was still a baby and she became pregnant again while taking progestin-only contraceptives. This drug is unlikely to interfere with breast milk production, but it is slightly less effective than regular drugs.
“Finance, housing, autos, it’s a lot,” she said. And another baby “isn’t really something we can do at this point.”
She said she made the long trip back and forth because she felt more comfortable getting abortion care at the office than receiving treatment from “someone I’ve never met” or receiving medication that was just sent to her.
Face-to-face care
In one of the examination rooms of the emergency hospital, Mr. A was sitting in a chair against the wall, quietly waiting for the doctor. Emergency doctor Victoria Kosukenoya knocked on the door, pulled up a chair across from her and greeted her warmly.
“Are you confident in your decision to move forward? Or would you like to discuss options?” she said.
“No, it’s already decided,” said A.
Ms. Kosukenoja previously worked in the family planning system. When she learned the Marquette clinic was closing, she started making phone calls in tears. She recalled asking all the medical personnel at Marquette, “What are we going to do?”
One of her first calls was to her friend and fellow emergency physician Brown. Their family harvests maple syrup together every spring.
In response to the closure of Planned Parenthood, Ms. Kosukenoja convened a community meeting at the Women’s Federation clubhouse downtown. The clubhouse was built in the 1880s, and guests drink from gold-rimmed china teacups on lace tablecloths. The goal is to brainstorm new ways to provide access to abortion in the Upper Peninsula.
Officials with the Planned Parenthood Association of Michigan said some brick-and-mortar clinics in the state have closed due to deepening financial difficulties and the Trump administration’s funding cuts, including to Medicaid.
Additionally, starting in 2022, the availability of pills by mail has exploded. Dobbs v. Jackson Women’s Health Organization decision was overturned egg. Telemedicine abortions have increased from 5% of all abortions provided to 25% by the end of 2024, even as abortion is illegal in many states, according to #WeCount, a national reporting project that tracks abortion trends.
Paula Thornton Greer, president and CEO of the Planned Parenthood Association of Michigan, said telehealth appointments for patients in the Upper Peninsula have increased by 13% since the Marquette store closed.
The abortion patients Koskenoja sees in her emergency room all have one thing in common. It means they want to talk to someone directly.
“I’ve had patients who ordered their medications online and were afraid to use them. They felt like they were going to mess up their medication, or they weren’t sure if they could rely on it,” she said. “So they literally walked in here with pills in their hands.”
Some people have complications or need an ultrasound to determine how far along the pregnancy is.
“I’m angry that telemedicine is considered acceptable in rural areas,” Koskenoya said. “Like we’re not the kind of people who like to talk to people or look people in the eye, especially when something serious is going on.”
Emergency treatment options
The options presented at that community clubhouse meeting were limited. The small number of family doctors and gynecologists in the area are either already putting patients on months-long waiting lists or have become too “right-leaning,” Brown said.
But urgent care is designed to fill gaps in the system and is ready to accept walk-in patients who aren’t already patients, she said.
From her years in the emergency room, Brown knew that medical abortions were not that complicated. The professional guidelines for first-trimester medical abortion and miscarriage are essentially the same. Administer mifepristone once, followed by misoprostol 24 to 48 hours later.
“Clinically, I wasn’t worried at all,” she says.
The biggest hurdle was obtaining malpractice insurance, Brown said. At first, she said, insurance companies were reluctant, demanding “tedious and unrealistic” paperwork and additional training. The annual premium for medication abortion was then estimated at $60,000. This is about three times the cost of insuring the entire emergency treatment. Ultimately, emergency care intermediaries pushed back, providing data that showed medical abortions did not add “significant liability,” Brown said.
The company agreed to pay an annual premium of about $6,000, he said.
The community has also been supportive. A local donor covered the ultrasound machine. Supporters also started a nonprofit organization to help with drug costs and additional staffing, lowering prices for patients from about $450 on a sliding scale to an average of about $225.
Once Marquette Medical began offering medical abortions, word spread quickly, Brown said. The office now sees up to four cases a week, with patients coming from as far away as Louisiana. Brown said the clinic is on track to match the number of abortion patients treated at local family planning offices before the closure.
Chernoby said with mail-in pills becoming the next major target for abortion opponents, it will be important to provide more care in more brick-and-mortar locations. Brown said the Marquette clinic is already fielding questions from a large academic medical center that plans to start offering medication abortions in its own urgent care later this year.
“It’s a great idea, but there could be major pitfalls,” said David Cohen, a professor at Drexel University’s Klein School of Law who studies access to abortion.
Urgent care practices that provide medication abortions must comply with state-specific laws (some requiring 24-hour waiting periods and facility structure requirements) and federal regulations, such as the FDA’s requirement that prescribers of mifepristone have a patient consent form certified and signed by the drug’s distributor.
If access to abortion is not core to a health agency’s mission, “do you want to be on that list? I don’t know if you’re going to be on that list,” Cohen said. “There’s just a very specific regulatory environment” when it comes to abortion.
make a choice
In the exam room, Ms. Kosukenoja listened to Ms. A talk about why she decided to have an abortion. There are four children in her house, including a baby.
“Can I do an ultrasound? Just to see how far along it is and to make sure it’s not an ectopic pregnancy,” Kosukenoya asked.
“Yes,” said Mr. A.
Mr. Kosukenoya focused on Mr. A’s reaction to the question. “Okay. Are you making faces?”
“Yeah, I don’t—Yeah, it’s okay. I just don’t want to see it.”
“Oh, you don’t have to look,” Kosukenoya said.
“I don’t want to hear the heartbeat,” Mr. A said.
“Definitely not,” Kosukenoya said.
After the ultrasound, Ms. Kosukenoya went out into the hall and gave Ms. A time to call her partner.
When A said he was ready, Kosukenoja cut in and asked how he was feeling. Mr. A has made up his mind. She said her partner would support her decision and that she had no intention of having another child for now.
“I know this baby will be loved no matter what, but now is not a good time,” Mr. A said quietly, placing his hands on his knees.
“Most people who get abortions love their babies,” Koskenoya says. And you can get even more in the future, she assured A.
This started a long conversation about the emotional toll of raising children and the pros and cons of various contraceptive options. Mr. A wanted to have his fallopian tubes tied, and Mr. Kosukenoya suggested that his partner consider a vasectomy. It’s a much less invasive procedure, she says. “You have a lot of kids. I think it might be his turn to be responsible.”
Kosukenoya handed her a small hand-sewn “comfort bag” that all medical abortion patients receive. Inside were pills, reminders about when to take them, handwritten notes of support from local residents, painkillers, comfy socks and heating pads.
“Call me if you need anything. Do you have any questions?” she said to Mr. A.
“No,” said Mr. A.
“Okay, good luck,” Kosukenoja said as Mr. A drove out, past a waiting room filled with sick babies and other patients, to drive back to the children.
