A few months after South Dakota banned abortion last year, April Matson drove more than nine hours to take a friend to a Colorado clinic to get the procedure.

The trip brought back difficult memories of Matson’s own abortion at the same clinic in 2016. The former grocery store worker and parent of two couldn’t afford a hotel and slept in a tent near a horse pasture — bleeding and in pain.

Getting an abortion has long been extremely difficult for Native Americans like Matson. It has become even tougher since the Supreme Court overturned Roe v. Wade.

New, restrictive state laws add to existing hurdles: a decades-old ban on most abortions at clinics and hospitals run by the federal Indian Health Service, fewer nearby health centers offering abortions, vast rural expanses for many to travel, and poverty afflicting more than a quarter of the Native population.

“That’s a lot of barriers,” said Matson, who lives in Sioux Falls and is Sicangu Lakota. “We’re already an oppressed community, and then we have this oppression on top of that oppression.”

Among the six states with the highest proportion of Native American and Alaska Native residents, four – South Dakota, Oklahoma, Montana and North Dakota – have moved or are poised to further restrict abortion. South Dakota and Oklahoma ban it with few exceptions.

In some communities, the distance to the nearest abortion provider has increased by hundreds of miles, said Lauren van Schilfgaarde, a member of Cochiti Pueblo in New Mexico who directs the tribal legal development clinic at the University of California-Los Angeles.

“Native people are having to cross massive, massive distances and absorb all of the travel costs and child care,” she said.

Experts say the issue should be seen within the larger context of the tortured history between Indigenous people and white society that began with the taking of Native lands and includes coerced sterilization of Native women lasting into the 1970s. Native Americans on both sides of the abortion debate invoke this history — some arguing the procedure reduces the number of potential citizens in a population that has been threatened for centuries, and others saying new restrictions are another attack on Native women’s rights.

Many advocates worry that reduced abortion access will make things even worse for women already facing maternal death rates twice as high as their white peers, teen birth rates more than twice as high as whites, and the worst rates of sexual violence.

“Indigenous women don’t have access to reproductive justice in any form, and that includes abortion,” said Natalie Stites Means, a member of the Cheyenne River Sioux Tribe who serves on the board of the Justice Empowerment Network, an abortion fund. “Any limitation on our health care and any limitation on abortion is going to impact our health and well-being.”

DECADES OF RESTRICTIONS

For centuries, experts said, Indigenous people had their own systems of health care, which in some cases included natural abortive practices.

Today, the main source of care for many is the Indian Health Service, which serves 2.6 million American Indians and Alaska Natives who belong to 574 federally recognized tribes in 37 states. Its clinics and hospitals operate under the Hyde Amendment, which bars them from using federal funds for abortions except in cases of rape, incest or threats to a mother’s life.

Even when an IHS patient falls under one of those exceptions, many facilities “don’t have the materials or staff or the expertise to provide that abortion care,” van Schilfgaarde said.

Matson uses the pronoun they and is two-spirit, a term used to describe those who combine traits of both men and women. Matson, who lived in Rapid City at the time, said IHS staff didn’t discuss abortion as an option for their unplanned pregnancy. After getting the procedure at 13 weeks in Colorado, they felt uncomfortable returning to IHS despite ongoing bleeding.

While IHS staff can refer people to places that provide abortions, federal funds can only be used for “Hyde-permitted” procedures and related patient travel, agency officials said in a statement. And a federal report shows nearly 1 in 5 American Indians and Alaska Natives are uninsured.

Also, there are often no abortion providers nearby. One reason? The proportion of Catholic health systems, which generally prohibit abortion, has grown significantly. A 2020 report by Community Catalyst, a nonprofit health advocacy organization, found that 1 in 6 acute care hospital beds in the U.S. is in a Catholic system. The share is 40% in South Dakota and 32% in Oklahoma.

SEEKING SOLUTIONS

After Roe fell, restrictive “trigger” laws took effect in more than a dozen states, including South Dakota and Oklahoma, which already had stopped providing most abortions. North Dakota’s abortion ban has been blocked in court.

Some Native women were inspired to organize.

Cherokee women in Tahlequah, Oklahoma, gathered over the summer to discuss a possible amendment to the tribe’s constitution protecting reproductive health access for its citizens. They were frustrated that leaders of this tribe with around 450,000 citizens hadn’t addressed the issue.

“Fear was just kind of palpable,” said group leader Alissa Baker, who teaches psychology at Northeastern State University. “We felt a need to protect our community … and really in some ways reclaim some of those traditional roles of a Cherokee woman, which is effectively being the voice of the community.”

But the effort stalled as the school year approached, with members spread across a rural area, busy with jobs and children.

Other activist efforts panned out. D’Arlyn Bell, a doctoral student at the University of Kansas and another member of the Cherokee Nation, joined with other Native activists to help defeat a proposed amendment to the Kansas state constitution that would have cleared the way for tougher abortion restrictions.

“We were doing it not only for the Native women in our own states but Native women from our own home territories, especially Oklahoma,” she said.

Experts stress that abortion views vary among tribal leaders and members – something echoed in a statement from the Cherokee Nation, the only one of the five largest tribes in South Dakota and Oklahoma to respond to a request for comment from The Associated Press.

Opening a clinic on tribal land would be legally challenging, experts said. The Cherokee Nation said it wouldn’t set one up, and there have been no announcements from other tribes since Roe was overturned. History shows the issue is fraught: The first woman president of the Oglala Sioux Tribe in South Dakota was impeached in 2006 after publicly proposing an abortion clinic on the reservation.

Post-Roe, Native Americans on both sides of the issue are taking personal and collective action.

Elizabeth Terrill, a board member for the anti-abortion Native American nonprofit Life is Sacred, said she’s a foster parent, does post-abortion counseling and supports moms. She said extended families on tribal lands historically have banded together when there is an unplanned pregnancy, and most women choose to continue them.

“I think there’s just a different cultural understanding of what life is and when life begins and why life is so sacred,” said Terrill, a mental health therapist near the Navajo Nation in New Mexico and member of the Osage Nation of Oklahoma.

Matson, executive director of the summer camp “Rock the Rez,” said they share their experience, donate money to those in need and tell others about resources like the Justice Empowerment Network, which covered most of their friend’s abortion and travel costs.

“Every time someone is going through this, I offer support,” said Matson, 32. “I’ve helped, I hope, in every way that I can.”

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By LAURA UNGAR and HEATHER HOLLINGSWORTH Associated Press. The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.