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Earlier this month the federal government issued a major regulatory change to allow pharmacy chains and local drugstores to dispense abortion pills for the first time. 

Viewed as in states like Hawaii where abortion is legal, the Food and Drug Administration cited in its justification for the rule change a years-old lawsuit by a small town doctor on Kauai.

Dr. Graham Chelius, a family medicine physician in a town of fewer than 2,000 residents on the island’s West Side, filed the 2017 legal challenge in an effort to open up new opportunities for Hawaii women to receive an abortion closer to home. He said the FDA’s “medically unnecessary” restrictions around abortion pill access disproportionately affect rural women on the neighbor islands.

The American Civil Liberties Union has represented Chelius in his complaint, which prompted the FDA to review its abortion pill restrictions. That review led to the Jan. 3 revocation of some restrictions around where abortion pills can be dispensed.

The move to make abortion pills more widely available comes at a time when abortion access is slipping away in many states. Roughly to choose to terminate pregnancy in their home states last year after the Supreme Court overturned the landmark Roe v. Wade decision in June. 

In Hawaii, strong laws protecting a woman’s right to terminate her pregnancy remain intact. And there’s no sign of any significant legislative effort to soften them. But access to abortion in Hawaii, particularly in rural parts of the state, is encircled by barriers.

“People say we have abortion access in Hawaii but we’ve been conflating access with legality,” said Khara Jabola-Carolus, executive director of the . “Like Rolexes are available at Ala Moana mall, but that doesn’t mean they’re accessible. For a teenage girl who doesn’t have a lot of money living in rural Hawaii, abortion might as well be a Rolex.”

Tens of thousands of women in Hawaii must board a plane to access an in-clinic abortion on Oahu. Alternatively, taking medications commonly known as “the abortion pill” to terminate an early pregnancy is complicated by a shortage of doctors willing to write the prescription. 

Nationally, the abortion pill is used in more than half of all abortions. The two-pill protocol can be used for pregnancies up to 10 weeks’ gestation.

Hawaii patients usually acquire abortion pills through mail-order pharmacies thousands of miles away. But the arrival of such time-sensitive medication has sometimes faced shipping delays that can threaten a woman’s ability to use it.

It remains unclear how significant the new ability of some Hawaii retail pharmacies to stock the abortion pill will increase access to women. At least one provider on Kauai is looking into what it would take to start dispensing the pill, according to Emma White, social justice advocate at the and a member of the Kauai Abortion Access Workgroup, newly formed by advocates seeking to expand abortion care on the island.

And while Oahu has multiple clinics where later-term surgical abortions are performed, Kauai, Lanai and Molokai have none.  

Although most health insurance providers will pay for the procedure and airplane ticket, there are hidden financial costs and logistical hurdles when air travel becomes a necessary part of the process. The cost of ground transportation typically falls to the patient. Lost wages factor in when a woman is forced to take a day off from work. And keeping an abortion confidential from employers, neighbors and friends can become more difficult when air travel is involved.

Some local abortion providers say air travel can be an insurmountable barrier, especially for women who are homeless, poor, in their teenage years, fearful of an abusive partner, unable to speak English, suffering from substance abuse or mental illness or living in a religiously conservative family or community.

, an advocacy group formed in the weeks after the Supreme Court overturned Roe v. Wade, has compiled , which are not always transparent. 

“Even as a health care provider it’s been challenging for me to find out exactly what services are offered by our biggest medical providers,” said Sharon Offley, an advanced practice registered nurse and midwife at on Kauai. 

“For some people there is a stigma around abortion that perpetuates some of this,” she said. “But I feel like pregnant people do deserve transparency in how they can access services.”

Beyond a lack of transparency, Hawaii Abortion Collective has identified dozens of other threats to abortion access in the islands, including deficits in statewide abortion infrastructure, coverage restrictions for people with federal insurance, moral or religious stigma, lack of coordination among providers and financial and geographical constraints. 

“That is a long list and if we’re going to tackle it at the Legislature year by year, even if we have a victory every year that could take 40 years,” Jabola-Carolus said. 

A more effective way forward, Jabola-Carolus said, is laid out in proposed legislation filed last week that would establish and fund a to tackle barriers to abortion access. The coordinator would also develop abortion training and continuing education programs for qualified medical professionals and establish neighbor island clinics to bolster abortion access in rural areas.

“Think of it as the statewide homeless coordinator but apply it to reproductive health care,” Jabola-Carolus said. 

Something else the coordinator could do is improve the efficacy of other recently passed legislation aimed at improving abortion access. For example, in 2021 allowed advanced practice registered nurses to perform abortions. But this does not appear to have significantly augmented the provider field, according to Dr. Reni Soon, an abortion provider on Oahu and Maui.

“I am personally not aware of any APRNs that have been able to perform abortion procedures because of issues with accessing training and issues with malpractice carriers not covering them,” she said. “There have been just a number of logistical barriers that I don’t think anybody really anticipated.”

Other proposed bills this year include designed to protect abortion providers and patients from prosecution in other states where abortion is unlawful and a language clean-up bill that would in the state’s half century-old abortion statute. 

In some cases, lack of access to abortions on the neighbor islands is not an issue of training. On Kauai, where there are no in-clinic elective abortion providers, doctors at the island’s two major medical centers perform the very same abortion procedure if a woman has a miscarriage, according to Offley. But the procedure is not offered for elective abortions — not even if the pregnancy is likely to result in a stillbirth due to congenital abnormalities.

“Medically, if the exact same woman comes to me and there’s no heartbeat, there’s been a fetal demise, then I can refer them to either of our two hospitals on Kauai that will take care of them,” Offley said. “It’s the same procedure (as an elective abortion) but if there is a heartbeat they have to go through this extra hoop of going to Oahu.”

is considering adding the abortion care to its menu of services, according to Malia Espinda, director of government relations and community affairs at Hawaii Health Systems Corporation, which offers surgical abortions at three of its other facilities on Oahu and the Big Island.

State law gives not only individual physicians but also entire hospitals  to participate in abortions. 

But even at some hospitals that have not officially opted out, doctors don’t have clear directives indicating whether they have the support from hospital administrators to perform elective abortions, according to White. 

“We’ve reached out to providers in hospitals or to hospital departments to see what abortion services they offer, if any, and it’s been pretty confusing,” White said, referring to the Kauai Abortion Access Workgroup, which formed this past summer after Roe v. Wade was overturned. “There haven’t been a lot of clear answers.”

White said their perception right now is that there isn’t much of a directive coming from hospital leadership on this issue so providers don’t know what bounds they need to work within.

“And so, of course, the default is to not do anything,” White said.

A lack of local data also blunts the state’s ability to bolster abortion access, advocates say. 

It’s unclear how many abortions take place in Hawaii in a given year. Not much is known about the characteristics of abortion patients, such as average age, socioeconomic status, whether she’s married or has children and how far along in the pregnancy she was when the abortion took place.

The Hawaii Abortion Collective is developing a survey to collect some of this information from abortion providers to develop a broad outline of abortion in Hawaii today and who’s most affected by logistical hurdles.

Civil Beat’s community health coverage is supported by , Swayne Family Fund of Hawaii Community Foundation, the Cooke Foundation and .