This is the first entry in a series tracking what it’s like to open an all-trimester abortion clinic in the U.S. as abortion rights are being curtailed.

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Late last year, Dr. Diane Horvath and Morgan Nuzzo decided they wanted to take the plunge and start their own business. They looked for funding from traditional and not-so-traditional sources, figured out creative ways to cut costs and hired lawyers to help them navigate the world of business leases, bank loans and incorporation documents.

It’s a journey familiar to entrepreneurs all over the country — but unlike Horvath and Nuzzo, those entrepreneurs aren’t opening an all-trimester abortion clinic.

It’s an unsettling time to be an abortion provider in America. At some point in the next few weeks, the Supreme Court could overturn Roe v. Wade, the 1973 opinion that established a constitutional right to abortion, sending the issue back to the states. Thirteen states would promptly ban the procedure, and another dozen could heavily restrict it. If that happens, abortion providers in the states where abortion remains legal would suddenly face a surge of out-of-state patients.

One state that’s likely to see an influx is Maryland, which is where Horvath and Nuzzo are opening their clinic, Partners in Abortion Care. In a country where abortion providers are increasingly on the defensive, both Horvath and Nuzzo are curiously upbeat. “The one thing that’s moving us along and making it so we’re not despairing is that we’re working toward getting this clinic open,” Horvath said. “We all want to burn shit down and light it on fire but we’re going to build something instead.” 

Why the Supreme Court almost overturned Roe v. Wade 30 years ago — but didn’t

But can they build it fast enough given the Supreme Court’s impending decision? By the time I met Horvath and Nuzzo, in April, they had been trying to get their clinic off the ground for five months. They had qualified for a business loan that they estimated would cover about a fifth of their costs, but they were still waiting to hear back from foundations that said they were committed to helping expand abortion access. In desperation, they set up a GoFundMe page, which ended up being a major source of funding: In just over two months, they raised more than $260,000. “I never thought I’d have to crowdfund an abortion clinic,” Horvath said.

When we spoke a few weeks later, Nuzzo told me she had a lead on a procedure chair she had found on Facebook Marketplace. “I’ll put it in our storage facility next to the ultrasound machine we bought on Craigslist,” she said. This sounds a little weird, Nuzzo was quick to add, but she said the equipment worked fine and they needed to make progress. “Why not just wait for our money to roll in and buy everything new? Well, we can’t if we want to open in the fall.”

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Opening a small business is never easy, but getting an abortion clinic off the ground comes with a special set of hurdles — particularly a clinic that offers abortions later in pregnancy. Even when timing and funding aren’t an issue, something as simple as finding a location can be incredibly difficult. Many landlords don’t want to rent to abortion providers, and local zoning laws sometimes restrict where abortion clinics can operate. Other businesses might also object to being located in the same shopping plaza as a facility that’s a magnet for protesters.

Because of these challenges, it’s relatively rare for a new provider not affiliated with Planned Parenthood or another existing clinic to find its footing. According to Caitlin Myers, an economist at Middlebury College who maintains a database of abortion providers who publicly advertise their services, 356 providers opened or reopened between January 1, 2013, and June 1, 2022, while 405 clinics closed, reclosed or stopped providing abortions.¹ About 58 percent of the newly opened or reopened clinics are connected to Planned Parenthood, and many others are part of established clinic chains. The impending fall of Roe has not changed this trend. Per Myers, as of June 1, only 10 clinics had opened since January, and just three more (including Partners in Abortion Care) were planning to open in the fall. Meanwhile, 20 clinics had closed or reclosed in the first five months of the year.

Horvath and Nuzzo are used to doing difficult things. A certified nurse-midwife, Nuzzo is something of an anomaly in her field. Maryland recently became one of a handful of states allowing certain health-care workers who aren’t medical doctors, like registered nurses and nurse-midwives, to provide both medication and procedural abortions, but it’s still uncommon for midwives to specialize in abortion. “The only reason I’ve been trained [to do abortions] is because I just kept hanging around and being like, ‘Can I try? Can I try? Do you think I could do this?’” Nuzzo said. Horvath, for her part, comes from a more traditional background and has been an outspoken advocate for abortion rights. In 2016, after the hospital she worked for tried to stop her from talking publicly about the abortions she had performed, she filed a federal civil rights complaint. 

Those kinds of barriers won’t exist at Partners in Abortion Care. Despite considerable pressure from potential funders, Horvath and Nuzzo decided not to incorporate as a nonprofit, so they are free to engage in political advocacy, something they plan to continue doing. “I remember when Trump said, ‘Oh, they’re ripping babies out of the womb at 39 weeks for abortion,’ blah, blah, blah, I got asked about it in a bunch of interviews,” Horvath said. “I was working for a nonprofit advocacy organization at the time, and the wording we landed on was something like, ‘Statements like that don’t represent medical reality.’ And I was like, ‘What we should be saying is, this is a fucking lie.’” (What Trump described does not happen.)

To find a space for their clinic, Horvath and Nuzzo worked with an investor who agreed to purchase a facility for them to rent in College Park, Maryland. That gave them the security of knowing they didn’t have to raise money to buy their own space, as their landlord was supportive of the clinic. But the clock was ticking. They had signed a lease, but by early June, when Roe seemed likely to be overturned any day, they still didn’t have the keys to the facility — which meant they couldn’t buy equipment or hire staff.

Getting into the space to start renovations was another barrier. After months of fruitless meetings with potential funders, they got a $300,000 grant from a small foundation, so between that and the GoFundMe money, Horvath and Nuzzo could finally afford to start paying themselves a salary three months before the clinic was slated to open. 

Even that timeline — which is speedy by the standards of starting any other business — wasn’t as swift as Horvath and Nuzzo had hoped. Ideally, it would have been better to open in June, before the Supreme Court’s ruling. Now, by the time Partners in Abortion Care does open, the landscape of abortion access could be completely different. And the number of people needing the services of an all-trimester abortion clinic will probably be higher.

Horvath told me about a third-trimester abortion she had performed with Nuzzo’s help. “I remember taking care of a very young girl who was like, stunned, the whole time,” Horvath said. The patient was confused because at that stage of pregnancy, an abortion involves a labor induction, which can hurt a lot. “She kept saying, ‘Why am I in all this pain?’” Later, when the girl was in recovery, Horvath turned to her and asked what she was most looking forward to when she got home. “And she goes, ‘I kind of just want to go back to being a kid again,’” Horvath said. “I had to go into my office and I just started sobbing. And I was like, ‘I will never be able to do anything else. Because this is where I need to be.’”

In some sense, that’s why Horvath and Nuzzo are so optimistic: At a moment of crisis, they have a job to do. I talked to Nuzzo one Friday afternoon in early June, when the Supreme Court’s decision could come out any day. “I feel very happy right now,” she said. “Roe might fall on Monday, but OK: We finally have money. Enough to open, I think. This is the moment, and we’re here. So I feel good about that.”