I have firsthand experience with one: Rhogam. Like 15 percent of the population, I lack the Rhesus factor in my blood, which means I have a negative blood type. If your partner has a positive blood type (or if their blood type is unknown), the fetus can inherit their factor, causing problems with the pregnancy. Pregnant people in this position can be given an injection of rho(D) immune globulin, such as Rhogam, to create antibodies that desensitize our physiological response if our blood comes into contact with the fetus’ blood, should it be Rhesus positive. Without the injection, it could be problematic for not only the health of the pregnant person and developing pregnancy, but the development of future pregnancies. Normally, Rhogam isn’t given during pregnancy until the 28th week, but abortion providers still routinely provide it at earlier gestations.

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I had the privilege of using insurance when I delivered my two children, including one through a cesarean section. Unexpected fees weren’t something I anticipated when I needed an abortion while living uninsured — and I live in Texas, where in 2017 a bill passed prohibiting insurance plans from providing coverage for abortion unless the pregnant person has a separate premium they’ve purchased specifically for abortion. And for most people, Medicaid won’t cover it, either. I learned I’d need to pay $100 because of my blood type, on top of $450 for a surgical abortion. My local abortion fund helped, but it wasn’t enough for me to afford Rhogam and sedation. So I experienced my surgical abortion completely aware, which wasn’t comfortable for me. Nor what I wanted, since medical settings give me anxiety.

Some clinics have taken measures to address the challenges of added fees. And abortion funds, such as the Mississippi Reproductive Freedom Fund, also provide financial assistance. Some abortion providers combine what would typically be additional costs with the price of the abortion, or try to be up front about these fees on their websites. But not everyone has access to the internet, or if they do, it isn’t always easy to find accurate information. Crisis pregnancy centers often use similar names to trick people, who may not realize they’re on a site that isn’t legitimate. So it isn’t unusual for us to learn — for the first time — that we have to pay hundreds of dollars upon visiting the clinic.

“We’ve had patients who choose our clinic specifically because we don’t charge for Rhogam,” one clinic told me. Other clinics may waive the fee for those who need help paying for it, when resources are available to do so. “We received a grant that allowed us to provide our patients with financial assistance for things, and at the time we decided to use it on Rhogam, so people wouldn’t have to miss their appointment over an unexpected thing,” another clinic said. “We recognize the hardship this creates for many people, especially when a lot of people have no idea what their blood type is to begin with.”

The extra cost of Rhogam increased the time one patient needed to pay back a loan they took out on their car in order to afford the procedure. “I had to travel to a different state because it was closer than the clinic where I lived. I had the money from a loan I took out already, but when I found out I’d need to pay $100 more because of my blood type — in addition to the barriers I was already facing — I realized I’d be stuck in this cycle of debt longer than I hoped for,” they said.

I also spoke with Desiree — whose name has been changed to protect her privacy. “I remember standing at the window and being told it would be an extra $100 because of my blood type. It had already taken me weeks to get the $400, and I needed an abortion a few days before rent was due. I had to step aside and really think about what this could mean for my living situation,” she said, since she’d already needed assistance from a local abortion fund.

Laurie Bertram Roberts, co-founder and executive director of the Mississippi Reproductive Freedom Fund, told TalkPoverty: “We hear from many callers that struggle more because of these extra costs. It’s already hard as it is to raise hundreds of dollars for the procedure, especially for our callers who are experiencing homelessness and other barriers related to accessing abortion.”

This issue also affects those who don’t have a negative blood type. “I wasn’t even Rh-negative, but the clinic I went to gives everyone Rhogam,” said another patient. She said the additional cost caused her to drive home on “fumes,” because she had to use her last $50 that was originally intended for gas after driving out of town for her abortion.

When it comes to the extra cost associated with Rhogam, fortunately, things are changing. In Contraception Journal, the National Abortion Federation (NAF) recognized last year that testing for the Rhesus factor in abortion care has become a barrier. They refer to Dutch guidelines, which say the injection is unnecessary for pregnancies less than eight weeks — and Sweden also recommends against the injection for early medical abortion.

NAF recently updated its recommendations regarding when Rhogam is required. They no longer recommend it for early abortions less than eight weeks, most of which are medical abortions and account for two thirds of the abortions performed in the U.S., according to the Guttmacher Institute. Now, people with a negative blood type — who find out about their pregnancy early on — may have the ability to forego Rhogam at NAF-member clinics. Some experts say it isn’t necessary for a first pregnancy at all.

Dr. Alice Mark, NAF’s Medical Director, told TalkPoverty: “We know giving the Rhogam injection at 28 weeks decreases the risk of sensitization, but what we don’t know is that any intervention before that has any impact on the outcomes…The studies [on sensitization] use methods that are outdated, and we were doing this intervention without knowing whether or not it benefited patients.” They drew heavily on data from Europe, where not providing Rhogam early in gestation has “no appreciable impact.”

Dr. Mark stressed that some clinics may want to follow American Congress of Obstetricians and Gynecologists (ACOG) recommendations to protect their patients, and that’s not wrong. “But because we’ve made this change, it’s been taken to ACOG to be discussed on their committees,” said Dr. Mark.

One clinic I spoke with told TalkPoverty that, “We’re going to follow the [NAF] recommendations, and we should be updating the guidelines in the next month. All of our physicians are really excited to follow these guidelines — there’s a lot of research on it. It’s an extra barrier for patients.” Patients are also growing more aware. “I didn’t need it because I’m less than eight weeks,” said one person I spoke with before her abortion.

This isn’t the fault of clinics. It is the result of the systemic issues related to extreme abortion restrictions. After all, paying for abortion could be a lot easier if there wasn’t a federal ban on public funding. Independent clinics perform the majority of abortions in the U.S., but they receive absolutely no support from our government. Use of state dollars for Medicaid reimbursements for abortions is highly restricted in Texas and a number of other states, so while some providers may combine these additional fees in the cost of the abortion, it’s inevitable not all would be able to in order to sustain the operation of the clinic. In eleven states, including Texas, most people can’t use their private health insurance for their abortion, either.

And with providers across the country facing closures due to medically unnecessary restrictions, accessing a clinic becomes less of a reality for many even without these additional costs. Next month, Missouri will give a final ruling in the case of the state’s only abortion provider shutting down. Six states currently have only one clinic, and Missouri could be the first with zero. In Texas, we have the most cities more than 100 miles away from an abortion clinic. For some of us, there is no choice: we’re forced to continue a pregnancy we don’t feel ready for.

Because even though we have a legal right to have an abortion, lawmakers continue to remind us that our right to choose means nothing if we can’t access it.

The other half? Paying to get to the procedure itself — a task that can cost hundreds of dollars on its own and eat up hours, if not days, of travel time in states that lack usable local public transit systems or mass transportation between rural and urban areas.

Nearly 20 percent of poor people lack their own vehicle, and the same states that pass paternalistic abortion restrictions are also the states least likely to spend infrastructure funding dollars on mass transit, considering it a form of “social welfare” for those too poor to own cars. States like Mississippi, Missouri, or Kentucky, which have just one clinic each, lack usable public transit within their borders, or easy access into major cities from suburbs and rural towns via train, light-rail, or even major bus lines.

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The limited number of abortion clinics — often paired with face to face waiting periods that are anywhere from one to three days apart — and the shortage of transportation infrastructure means that low-income patients without a car are often forced to hire taxies and other car services, rent vehicles, or navigate an expensive bus or train schedule at a time when they are emotionally and in some cases physically vulnerable, too.

“We’ve had patients use Uber to get to [Jackson Women’s Health Organization] in Jackson [Mississippi] from Oxford or Hattiesburg,” Laurie Bertram Roberts, director of the Mississippi Reproductive Freedom Fund, told TalkPoverty. “I didn’t even know you could go that far.” The cost? Around $200 for a 90-mile trip.

The logistical challenges quickly pile up. Alabama — which has three clinics spread throughout the state — has Amtrak, but the route through the state is limited and scheduling is difficult. This makes navigating the transit options a search for the right combination of trains and bus routes — often shuffling the same patient from bus to train and back again. Abortion funds — organizations that offer financial support for those seeking out a pregnancy termination — can offer gas cards, but that still requires patients to have a car to begin with. For those in one-car families, that also means letting another family member or friend into a very private, personal decision, too.

Amanda Reyes, co-founder of the Yellowhammer Fund, an abortion funding and practical support group for pregnant people in Alabama, said for patients outside a city — even just in the exurbs of the cities that do have clinics — renting a car is often the only solution. But for people who are low income and lack not only the funds for renting but also the credit cards, debit cards, or checking accounts needed to rent a car in the first place — about 20 percent of Americans are considered “unbanked or underbanked” — this can be nearly impossible. Because of Alabama’s requirement that patients visit a clinic and then wait 48 hours before returning for a termination, the car is needed for multiple days; the Yellowhammer Fund typically rents cars for a week.

“That’s why we got ourselves a van,” said Roberts. Now, with a van that can get patients from far out cities or towns to the only abortion clinic in Mississippi, Roberts is able to help some patients avoid that extra expense. It’s assistance that no doubt means even more to some local abortion patients who may hire a cab from one of the city’s taxi companies only to have it arrive with “Choose Life” etched into the side of the car’s body, according to Roberts.

Getting to a clinic without a car is a nightmare even when the provider itself is only a 15-minute drive away. Hiring taxis, Uber, or Lyft always means providing a name, and often a home address, to a driver. That can be especially difficult when ride app drivers refuse to serve neighborhoods that are predominately black or even refuse a ride once they realize the client is a person of color, as once happened with one of Roberts’ clients. In St. Louis, where Missouri’s only abortion provider is currently fighting the state to keep its doors open (it was just granted permission to continue operating until early August while it awaits a final decision), getting from a home in the north side of the city to the St. Louis Planned Parenthood can take hours, simply because the busing system exists as a means of keeping neighborhoods segregated from each other, rather than interconnected.

“The bus system is woefully underfunded and not super accessible for most people,” explains Alison Dreith, former executive director of NARAL Pro-Choice Missouri and current deputy director for Hope Clinic in Granite City, Illinois, which is just 10 minutes across the river from St. Louis. “It doesn’t go into North St. Louis, which is primarily a poor, black community. It would take multiple buses and transfers. It’s not just accessible.”

Then there is the more complicated — but not entirely rare — case of the patient who is worried about domestic violence, abuse, or has other safety concerns that make it necessary to hide the entire process from their partners, families, or the person who got them pregnant. “I spent 45 minutes calling every rental car agency in Birmingham,” Reyes told TalkPoverty, explaining the extra steps required to help a patient who was getting an abortion without informing an abusive spouse, and who needed to cover her actions along the way. “She couldn’t take a bus, she needed to rent a car, and she needed to be able to do it using cash so he wouldn’t see a charge for it. To get a car that way, you have to call the day before to see if anything is available.”

Cash-only rental cars often require the cash upfront, in addition to $300 or more in deposits in case of damage or theft. While an abortion at seven weeks would only be around $600, the costs for travel and other support were expected to be nearly three times that amount for Reyes’ client. It is just one of the many ways that a patient can be blocked from obtaining an early abortion and instead require a termination in the second trimester, instead, where the cost of an abortion rises with each additional week of gestation.

Getting the money for an abortion when you are poor and in a conservative state or rural community is only half the battle. Without an adequate public transit infrastructure, those with the ability to afford a termination may become trapped in pregnancies they do not want, simply because they lack the means to make it to their appointments. And the same legislators who have starved off transportation infrastructure in the name of rejecting “social welfare” will then deny those pregnant people any medical assistance, accessible contraception, living wages, childcare or safe housing, all while being the ones who forced them into this impossible situation in the first place.

In 2011, the Texas state legislature barred Planned Parenthood from its Medicaid program and excluded from state health plans any clinic affiliated with an abortion provider. This policy decision has had damaging consequences for some of the most vulnerable women in the state. A recent report found that in counties where Texas defunded Planned Parenthood affiliates, there was a dip in usage of long-acting reversible contraceptives (LARCs) and injectable contraceptives—the most effective forms of contraception available. During this time period, there was also an increase in births to mothers covered by Medicaid. Given that this surge in births occurred in the very counties where women faced new barriers to accessing contraceptives, it is highly probable that many of them were unplanned.

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These troubling outcomes are also likely attributable to the Texas omnibus abortion law—known as the Targeted Regulation of Abortion Provider (TRAP) law—which went into effect the same year that Planned Parenthood was excluded from state health plans. TRAP includes a number of provisions that make it more burdensome for women to obtain abortions. Among the provisions are bans on abortions that occur after 20 weeks, restrictions on medication abortions, and a requirement that physicians have admitting privileges at a hospital within 30 miles of where they perform abortions. A challenge to the law is currently before the Supreme Court.

Together, these restrictive policies have threatened not only women’s reproductive health and autonomy but also their economic security. Women without coverage are more likely to forgo care in order to prioritize other basic needs like food, rent, and childcare. And some low-income patients in states with restrictive abortion laws now face prices that are triple the cost of what women in states with access and availability pay for care. The scarcity of these services also means that many women have to travel hundreds of miles to obtain annual wellness visits, cancer screenings, and maternal care. Many of these women will lose wages to travel time and, adding insult to injury, will incur the additional expenses of transportation, food, and childcare.

Perhaps most horrific of all, we know that women who have lost access to services are now attempting to self-abort in the absence of accessible and affordable abortion care. The true irony is that by enacting harmful policies targeting abortion—a safe and legal medical procedure—policymakers have jeopardized the ability for low-income women in particular to make timely and informed decisions about reproduction.

And yet, the abortion war continues to rear its ugly head. In 2015 alone, 17 states passed more than 50 abortion restrictions. Eleven states slashed funding to Planned Parenthood or any clinic that provides abortion care among its health services. As states continue to introduce this kind of harmful legislation under false pretenses, one truth remains the same: the legal right to abortion and other reproductive health services means nothing without the ability to affordably and reasonably access it.

While the Supreme Court weighs the merits of Texas’s TRAP law, and the women of Ohio brace for an uncertain future, these states should be a cautionary tale not only for 2016, but for years to come.

Since Roe over four decades ago, the Religious Right has used the emotional juggernaut that is their rhetorical reach to shift the focus away from the health, security, and freedom of women and families. Instead, they propagate a narrow and misguided morality that seeks to control women’s bodies without concern for the needs in their lives and to embed a shaming narrative about abortion into the national psyche. Anti-abortion activists have employed these twin strategies—limiting access and shaming women—relentlessly for over 40 years. Unfortunately, in many ways they have been successful.

The first and likely most corrosive victory of that strategy is the Hyde Amendment, passed in 1976, three years after Roe. Hyde, which was framed as a compromise bill that stopped short of a full ban on abortion access, restricted the use of public funds for abortion. However, author of this amendment Representative Henry Hyde, was very clear about his motives around the compromise:

“I would certainly like to prevent, if I could legally, anybody having an abortion, a rich woman, a middle class woman, or a poor woman. Unfortunately, the only vehicle available is the [Medicaid] bill.”

Unable to make abortion illegal for all women, Hyde settled for a targeted assault on the options available to poor women. This attack set the stage for the ongoing strategy that Hyde’s acolytes have used ever since. Instead of directly contesting the legality of the issue, anti-abortion activist-legislators have tried to restrict access, availability, and affordability to ensure that abortion is legal only in theory for millions of women.

In many states, the anti-abortion movement has successfully constructed roadblocks to access, such as requiring women to have an ultrasound and look at the image before having abortion or mandating that they attend counseling services. Other legislators have sought to shame minors seeking abortions by limiting or erasing their rights to privacy. Still other anti-abortion legislators have pursued targeted regulation of abortion providers (otherwise known as “TRAP” laws) in the hopes of enacting regulations so burdensome that providers will be forced to close. These efforts to limit access to safe abortion services have been enormously successful.

On the forty-second Roe anniversary, a commentator said, “we no longer have the health crisis of women dying in ‘back alleys.’” Just one year later, that statement is not completely true, particularly for people of color and poor people, like a rural Tennessee woman who has been charged with attempted murder after trying to abort a fetus with a coat hanger. And in other states, women are making unsuccessful abortion attempts of the sort Roe supporters had hoped to eradicate. The clock has turned back in a most vicious way.

And, as some faith voices have supported each of these attacks, some people have been given the impression that all people of faith are against comprehensive health care that includes abortion services. But, what is often obscured is that, before Roe, faith leaders who understood the necessity of family planning in the battle against poverty were in the trenches helping women access safe abortions before legal abortion was available. Because of the desire for human flourishing—present in every faith tradition—progressive faith leaders are still driven to ensure women can access the care they need as opposed to shaming them for their health care decisions. Despite amplified voices suggesting the contrary, many people of faith still broadly understand full-spectrum women’s health care as a primary tool for the building of healthy communities. And, reproductive justice advocates understand a woman’s faith as inseparable from the rest of her lived experiences and attend to spiritual health as seriously as they do all other identified needs.

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We will only be able to truly celebrate Roe when all women have access to abortion services without the stigma and judgment of others. For these reasons, as we pause to reflect on this forty-third anniversary of Roe v. Wade, progressive people of faith must raise our voices in support of the women in our faith communities. The time for staying publicly silent has long passed. Instead, if we care about women of color, low-income women, and families whose fates are too often at the mercy of anti-abortion politicians, we must be bold in our challenge to faith narratives that shame and blame. We must fill the public sphere with language of love and kindness rather than judgment and ire. We must stand up for women of faith because seven in ten women who seek abortions report a religious affiliation. Some of them will look to us for guidance. We owe them our support, our love and our voices in protection of their lives. We must not fail them!

In truth, the promise of Roe existed in both spirit and law for just 2 years. From 1973-1975 abortion was legal and covered by the Medicaid program, which ensured that low-income women had equal access to abortion care. But in 1975, Congress passed the Hyde Amendment that restricted federal dollars from paying for abortion services for poor women. Since then advocates, activists, and legislators alike have struggled to maintain the essence of Roe as state legislatures took the lead on passing laws reminiscent of a pre-Roe era.

For decades reproductive health, rights, and justice advocates have fought to protect the legalization of abortion only to see its access and availability eroded at both the federal and state levels. At the federal level, the Hyde Amendment spawned similar amendments that restrict abortion coverage for military personnel, veterans, federal employees, Peace Corp volunteers, Indian and Native women, and incarcerated women. And in 1992, the Supreme Court issued a divided judgment in Planned Parenthood of Southeastern Pennsylvania vs. Casey that weakened Roe considerably. On the one hand, it upheld key provisions of Roe, namely that states cannot ban abortion before the point of viability of the fetus. But it also ruled that states could regulate abortions to protect the life of the woman or the fetus; medical technology could alter the point of viability; and, no law could impose an undue burden on women to obtain legal abortion services. Moreover, the court found that the 24-hour waiting period laws were not an undue burden. This Supreme Court decision, unfortunately, is the law of the land.

These federal budget amendments and Supreme Court rulings opened the door for state legislators to incrementally – and creatively – circumvent a woman’s right to determine if and when she will parent and to do so with dignity. Thus far, states have been allowed to pass extreme restrictions, and in doing so perpetuate a cycle of oppression for the most vulnerable women, namely those living in states with high rates of poverty, limited access to preventive services, and other regressive policies such as voter ID laws and right-to-work laws. According to the Guttmacher Institute, 30 states have enacted more than 205 abortion restrictions since 2011.

Texas, the poster child for anti-woman policies, offers proof of just how burdensome accessing abortion services can be for low-income women and families. Since 2013 Texas has cut family planning services and passed a law requiring doctors to have admitting privileges to a hospital within 30 miles, as one provision of the Targeted Regulation Abortion Providers (TRAP) legislation. Since the TRAP legislation passed Texas has gone from having 41 clinics to 17. A federal appeals court will determine this year if the TRAP building code provisions – such as the widening of hallways and increasing airflow – are constitutional. These new laws, combined with an already long list of restrictions, have made Texas one of the most hostile states for women’s health in the nation.  Previous restrictions include mandatory counseling that is biased; a 24-hour waiting period between counseling and having the procedure; mandatory ultrasounds; a prohibition on Medicaid coverage; and a prohibition on medication abortion provided via telemedicine.

Moreover, the cost for low-income women can be devastating. In Texas, one in six women must drive in excess of 200 miles to reach a clinic providing services. The 24-hour waiting period almost guarantees that those arriving from border towns or rural areas will have to pay for a hotel. If she is already a parent, as most women who have abortions are, she may need to pay for childcare too. Those working in low-wage jobs most likely do not have paid leave and could risk losing income or job if they take time off. And the cost of first trimester abortions without insurance coverage is approximately $500. But the longer a woman waits, the higher the costs will be. Research shows that too often women forgo basic needs – like paying rent – in order to obtain this legal medical procedure. Collectively or individually, these factors can force low-income women into worse financial circumstances.

We celebrate Roe as a standard and a vision that we must continue to strive for as a nation. All women, regardless of age, gender, income, socio-economic status, or funding source of insurance should benefit from its promise. And our fight for justice isn’t done until all woman have comprehensive reproductive health care, including the access to abortion services.