The West Alabama Women’s Center in Tuscaloosa has new art on the walls of its spruced-up waiting room and a quieter vibe than last year, when it acted as a magnet for protesters carrying bullhorns and speakers.

Things have changed below the surface, too, for the facility that once served as the busiest abortion clinic in Alabama. Last year, the U.S. Supreme Court ruled that states could outlaw abortion. As soon as the ruling came down, its providers stopped terminating pregnancies and helped about 100 patients shift their care to a clinic in Atlanta.

After a brief closure, West Alabama Women’s Center reopened last year with a different set of services, providing birth control, testing for sexually transmitted infections and prenatal care to local patients. On a recent Tuesday morning, medical director Dr. Leah Torres saw two patients nearing the ends of their pregnancies, both of whom had struggled to piece together care in the first two trimesters. Prenatal care has emerged as a major part of the clinic’s new offerings, a transformation that Marty said embodies her longtime goal to serve the state’s most vulnerable women.

“I think it’s completely consistent,” Marty said. “I have always been an activist whose major focus was the fact that people should be able to control their bodies in any way possible.”

Two of Alabama’s five abortion clinics closed after the ruling in Dobbs vs. Jackson Women’s Health Organization. The remaining three have stopped offering terminations, but still provide other types of care.

Although adding prenatal and contraception care had always been part of Marty and Torres’ vision for West Alabama Women’s Center, the abrupt shift away from abortion has been difficult to navigate. Marty immediately encountered a maze of bureaucratic hurdles that have kept the clinic from having access to federal grants and drug reimbursement programs that make it easier to offer low-cost care. And the transition from a cash business providing abortions to a clinic that bills Medicaid and private insurance has taken longer than expected, leaving the center without reliable streams of income.

“We have applied for a grant that would be a year’s worth of funding, but we won’t know until September if we made it to the next round,” Marty said. “And I’m out of money in October if I don’t raise more.”

Marty and Torres have pledged to provide affordable care, but it’s expensive, and the clinic often loses money providing things like IUDs or supplies for women who may need to test and control their blood sugar, Marty said. Uninsured women are more likely to be in poor health when they arrive at the clinic and need more intensive, expensive treatments for conditions like preeclampsia or gestational diabetes that can cause complications or death.

The costs have drained the center’s bank account, and Marty has been fundraising constantly. She and the clinic have managed to tread water for a year.

“Those are the people we are really focused on at this moment, but unfortunately those are the people who both need the most care and are the most expensive and this is something we are not charging for,” Marty said. “We have raised $1 million in the last year and spent $1 million.”

Marty has another fundraiser planned soon. And she continues to work on the structural problems that have kept the clinic from gaining access to federal grants and insurance reimbursement.

Still, she said the clinic has struggled to make the transition in part because of the way abortion became illegal in states across the South. Marty said she believed the end was coming in December 2021, after a hearing at the U.S. Supreme Court in the Dobbs case. She knew Alabama had laws in place that could immediately kick in depending on how the justices ruled on the case.

“At that point, that was when we started planning for our pivot,” Marty said. “But we were basically stuck in this rock-and-a-hard place situation where we could have started to do all the processes that we needed in order to turn ourselves into a full-scale reproductive health center. But we didn’t have the time because there were still so many patients who needed abortions.”

Instead of winding down the abortion practice, the clinic ramped it up, accepting patients fleeing from places as far away as Texas, where laws had already limited termination. The average number of patient visits increased from 200 a month to 250, she said.

The number of average monthly patients has now dwindled to between 80 and 100, Marty said. But the patients they see now require more intensive care. Torres, who had moved to Alabama to provide abortions, said she chose to stay to help the women left behind.

“We knew before Dobbs happened that healthcare was not accessible for people without money,” Torres said. “The healthcare that was accessible was not the best quality. And then Dobbs happened. So that was only going to get worse.”

Although there has been a decrease of recorded abortions in Alabama and across the nation, so far health officials have not reported a surge in births. A spokesperson for the Alabama Department of Public Health said preliminary data shows a slight uptick in births and a slight decrease in infant mortality. Those numbers may not be complete, she said. Torres, who is trained as a gynecologist/obstetrician, has spent the last year caring for many women who have fallen though the cracks in the state’s safety net system.

“In order to obtain Medicaid of Alabama insurance, and one presumes that one is applying for Medicaid because one doesn’t have insurance, a doctor needs to administer a pregnancy test and write a letter,” Torres said. “Guess what’s really hard to do? Get a doctor’s appointment when you don’t have insurance.”

The West Alabama Women’s Center isn’t the only abortion organization that has pivoted to helping pregnant women in the wake of Dobbs. The Yellowhammer Fund, which provided money to patients to pay for abortions, has diverted part of its resources to providing diapers and other supplies to new moms. They also provide information about contraception and organizations that fund out-of-state abortion care, although they cannot directly assist people who want to terminate pregnancies. Jenice Fountain, executive director of the Yellowhammer Fund, said a handful of donors have pulled out so they can direct their funds to places where abortion remains legal.

“I’ve told them that’s a very dangerous stance to take for people in Alabama that are suffering under conservative legislation,” Fountain said. “People are still going to need care.”

Marty said it has been more difficult to raise money for the clinic after abortions stopped. When the Dobbs decision was announced, Marty took to social media to seek funding to help the remaining 100 patients scheduled for procedures travel to facilities out of state. About $180,000 flowed in over the next couple of days. It has taken an entire year for her to raise the same amount from small donors to keep the center afloat serving patients with contraception or prenatal care.

Marty said she wants to stay and do what she can to keep serving patients in an around Tuscaloosa.

“What we are doing, in my opinion, is just as important,” Marty said. “And it’s not just about the birth control and the prenatal care and the HIV and the trans. It’s about the fact that we know there are people who are going to be doing their own abortions. We want them to know that this is a safe place for them to go to if they have complications.”