Last year around this time, Tammy, her husband, and their young son were getting ready for a big expansion of their family: she was expecting twins – one boy and one girl.
The family celebrated around Christmastime with a gender reveal party, complete with matching onesies reading, "Little Brother" and "Little Sister."
"It was great, and I think my husband I would both say that that was probably the highest point of what had already been a difficult pregnancy," she said.
Tammy, 37, is a teacher from the Atlanta area. We're not using her last name because she's worried about facing stigma for sharing her story.
A 'Painful and Difficult' Decision
There were some worrisome test results earlier in the pregnancy, but the couple decided to wait things out. Then, around 25 weeks, Tammy said she and her husband learned their daughter had a rare condition that could mean a lifetime of seizures, heart problems, and developmental delays.
"Thinking about having twins after already having a toddler and then one of those twins constantly being in and out of the hospital – I don't know how I'd be able to give enough love and attention to my boys," Tammy said.
Georgia bans most abortions after 22 weeks; it's one of many states that restrict abortion later in pregnancy. And few physicians nationwide are willing or able to perform such procedures.
Tammy was referred to a clinic in Boulder, Colo., founded by Dr. Warren Hern, who specializes in later abortions.
"The women who come to me are in extremely difficult circumstances; this is the most painful and difficult decision of their lives," Hern said in an interview with NPR.
Tammy's case was particularly complex because of the other twin, who was born healthy a few weeks after her procedure.
Many Restrictions, Few Options
A ballot initiative before Colorado voters threatens to shut down Hern's clinic, where he estimates that like Tammy, about 85 percent of his patients come from outside Colorado. Most of the procedures performed at the clinic in Boulder would be banned under Proposition 115, which would prohibit abortion after 22 weeks except to save a woman's life. Doctors found in violation could face fines and lose their medical license.
Hern said many of his patients are facing a medical crisis; others have been victims of rape or incest and may have faced delays in getting an abortion.
"And so I think these are very private decisions," Hern said.
Later abortion is relatively rare – a little more than 1 percent of abortions nationwide occur after 21 weeks, according to the Guttmacher Institute, which supports abortion rights.
The 22-week cutoff is close to the earliest point when doctors say a fetus could survive delivery with significant medical intervention.
Tom Perille, a Colorado physician and advocate for the abortion ban, argues allowing abortion at that stage is cruel and out of step with much of the rest of the world. He said women should make the decision earlier.
"Women have 22 weeks to continue to make their choices about the pregnancy – including in the tragic situations of rape, incest, and fetal anomaly," Perille said.
'Some Type of Proof'
For several anxious months, Leah, who also asked us to use her first name, waited to decide whether to terminate a complicated and high-risk pregnancy.
"It was just something I always wanted to be, was to be a mother," she said.
Leah, 29, was told there might be problems with the fetus, and that the pregnancy could worsen her own longstanding health problems, even threaten her vision.
"I just needed to have some type of proof," she said. "And if I was never gonna get that proof, I was going to stay pregnant."
Leah says she finally got that proof, in devastating form, around 24 weeks – when she was told her fetus had a fatal condition. It was too late for an abortion in her home state of Iowa, so she traveled to Colorado.
Nerys Benfield, a physician based in New York and board member for the Society of Family Planning, said there are many reasons why patients sometimes seek abortions later in pregnancy. Some fetal abnormalities can develop later in pregnancy, and others are difficult to diagnose early on.
Benfield said some women also are delayed in beginning prenatal care.
"Maybe they didn't know that they were pregnant; they've got irregular periods; they're just kind of not aware until later in the process," Benfield said. "We also have areas [of the country] where getting access to care is very hard."
Groups including the American College of Obstetricians & Gynecologists are opposing Proposition 115 on the grounds it will interfere with the doctor-patient relationship and complicate difficult medical decisions.
Some supporters of the initiative say they hope it will shut down Hern's clinic, and pave the way for more abortion restrictions in the future. In an interview last year with Denver radio station KHOW, activist Erin Behrens suggested she hopes it's just the beginning.
"Let's get that passed; let's get that on the books; let's put the Boulder abortion clinic out of business and prevent those lives from being taken every year," she said. "And then let's come back and talk more about it in 2022 and 2024."
Recent polling indicates a narrow split among voters on the 22-week abortion ban. Whatever they decide on Tuesday will have implications for pregnant women well beyond Colorado's borders.
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