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Abortion is still legal in the United States, but for women in vast swaths of the country it’s a right in name only.

Six states are down to only one abortion clinic; by the end of this week, Missouri could have zero. Some women seeking abortions have to travel long distances, and face mandatory waiting periods or examinations. On top of that, a new wave of restrictive laws, or outright bans, is rippling across GOP-led states like Alabama and Georgia.

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Both sides of the abortion battle are focused on the future of Roe v. Wade, but opponents have already won the ground game over the past decade, chipping away at abortion access.

The Supreme Court’s new conservative majority, about to wrap up its first term, has not yet taken up a case challenging Roe. Just this week it declined to reinstate an Indiana law, signed by Mike Pence when he was governor, that would have banned abortion on the basis of gender, race or fetal disability. But that’s no guarantee the court won’t take another look at the landmark 1973 abortion rights ruling.

But even without the high court, GOP-backed laws have added restrictions and obstacles, whittling away access. Since the start of the Trump administration, hostility to abortion in general and Planned Parenthood in particular has only intensified in statehouses around the country.

“We celebrate freedom in America. But I believe that my choice ends when another life begins,” Louisiana state Rep. Valarie Hodges said just before a fetal “heartbeat” abortion bill passed there.

Years of piecemeal state laws have left their mark. Mandatory waiting periods, travel, missed work and lost wages all make getting an abortion more expensive and more difficult, particularly for low-income women. Doctors and clinic staff have to face protesters, threats, proliferating regulations and draining legal challenges; clinics have closed. In remote parts of the midwest and south, women may have to travel more than 300 miles to end a pregnancy.

“This is a moment of seeing how all of these laws fly in the face of medicine and science and go against what we in the medical profession know, which is that any restriction on medical care by politicians will endanger people’s health,” Planned Parenthood President Leana Wen, a physician herself, said in an interview.

It’s intensified of late. Republicans in Alabama and other states have raced to enact laws that would almost completely ban abortion, sometimes without exceptions for pregnancies that result from rape or incest. Eight states have enacted laws which, if allowed to go into effect, would ban abortion once a fetal heartbeat can be detected, as early as the sixth week of pregnancy, when many women don’t even know they are pregnant. (Missouri’s variant is eight weeks.) Alabama has gone even further, granting “personhood” and legal rights from conception.

Those laws may eventually reach the Supreme Court and test Roe, the 1973 decision that recognized women’s right to abortion. But those statutes aren’t what’s crimping access nationwide right now. That’s happened through a drip, drip, drip of lower-profile efforts that have created obstacles for pregnant women and led to a dwindling supply of doctors trained and willing to perform abortions.

Many of those laws were promoted as attempts to make abortion safer — though courts often disagreed and threw them out as unconstitutional barriers. Now, abortion opponents are openly talking about ending the practice altogether.

“The strategy used to be death by a thousand cuts,” said Colleen McNicholas, a physician based in St. Louis who also provides abortions in Kansas and Oklahoma. “They’re no longer pretending things are to promote the health and well-being of women, which is what we used to hear all the time. Now they’re being very bold and upfront.”

“It doesn’t change the fact that for many Americans, particularly for women in the middle [of the country] and the South, abortion is inaccessible,” she added.

Data from the Guttmacher Institute, a research organization that supports abortion rights, shows that 788 clinics in the U.S. provided abortion services in 2014 — a drop of 51 clinics over three years. Since 2013 about 20 clinics have closed just in Texas.

Further, one in five women would have to travel at least 43 miles to get to a clinic, according to a Guttmacher analysis from October 2017. In North Dakota, South Dakota and Wyoming, at least half of the women between 15 and 44 years old lived more than 90 miles from a clinic.

Six states — Kentucky, Missouri, Mississippi, North Dakota, South Dakota and West Virginia — have only one clinic left that performs abortions, according to a recent analysis from Planned Parenthood and Guttmacher. Lawmakers in many of those states have pursued limits in when abortion can be allowed — such as fetal heartbeat laws or 15-week bans, though the laws have been blocked in court. Four of those states have also passed so-called trigger laws that would ban abortion immediately should the Supreme Court overturn Roe.

In Missouri, the sole clinic, which is in St. Louis, could close this week. On the surface, it’s a dispute with the state health department over licensing, safety and regulation, but the showdown comes just days after state lawmakers passed a ban on abortion after eight weeks of pregnancy, with no exceptions for rape or incest.

“States have been marching down this path for a number of years. The restrictions that have passed previously have set the stage for the bans this year,” said Elizabeth Nash, Guttmacher’s senior state issues manager. “It’s counseling, it’s waiting periods, it’s abortion coverage in your health plan. It’s limits on abortion providers, such as unnecessary clinic regulations.”

“Missouri is the first and other states could be next,” Planned Parenthood’s Wen said on a recent call with reporters.

The ramifications of the anti-abortion movement’s sustained assault against Planned Parenthood are perhaps no clearer than in Texas, where lawmakers have passed dozens of restrictive laws, including mandatory ultrasounds, waiting periods and state funding restrictions.

The Supreme Court overturned another set of Texas restrictions in 2016 — but not before about 20 clinics shut down, many of which were never able to reopen. Providers retired, staff found other jobs and clinics had to start from scratch to get licensed and staff up. “All of those things take time and a significant amount of money,” said Kari White, an associate professor in Health Care Organization and Policy at the University of Alabama at Birmingham and an investigator with the Texas Policy Evaluation Project.

Even though Texas permits abortions until 20 weeks — itself a cut-off point that conflicts with Roe v. Wade, although it hasn’t yet come to the Supreme Court — abortion access has sharply declined. That scenario is likely to play out in other conservative states, even if they don’t go as far as Georgia or Alabama.

More than half of Texas’ 41 abortion clinics closed or stopped performing abortions after the state passed legislation in 2013 that bundled several onerous restrictions, according to research from the Texas Policy Evaluation Project. The average distance a woman had to travel one way for an abortion jumped to 35 miles from 15 miles. In rural parts of the state, drives of 100 miles or more to access care are not uncommon, according to the group.

The evaluation project found that while the number of abortions overall declined after the Texas law went into effect, the number of second-trimester abortions rose as women were forced to wait and travel longer distances. Currently only about 22 abortion providers, mostly in urban areas, are operating in Texas, a state with roughly 6.3 million women of reproductive age.

Low-income women are disproportionately affected by abortion restrictions, said Kamyon Conner, executive director of the Texas Equal Access Fund, which helps women who can’t afford an abortion, which costs between $500 and $10,000 dollars depending on the point in pregnancy. The nonprofit was part of a group that challenged dozens of Texas abortion restrictions in court.

Calls to the group’s hotline have tripled over the past few years to 6,000 in 2018, but it only funded about 1,000 women last year, she said. Some of those women are undocumented immigrants, some are incarcerated and others have children but cannot afford to raise more.

Other costs mount — both in money and time, Conner said. Because Texas has a 24-hour waiting period between an initial consult and the abortion, women miss work and may have to pay for hotel rooms.

“There are fewer clinics to provide the services,” said Conner. “The few clinics that are left are in very high demand.”

Telemedicine could plug some gaps in care for women seeking abortion medication, instead of a surgical abortion. But there too access varies widely by geography. Some states ban telemedicine-facilitated abortions. Elsewhere, providers are using video-chat technology to dispense the medication. Seventeen states require licensed abortion providers to be physically present when administering abortion medication, which effectively is a ban on telemedicine, according to the Guttmacher Institute. Abortion medication is approved for use up to ten weeks into pregnancy, but under current FDA rules can only be dispensed at certain medical facilities, including abortion clinics.

Alternatives are being tested. In one FDA-reviewed study, clinicians can mail abortion medication directly to patients after a video chat. Study participants can go to any clinic for their screening and ultrasound, send the results to a participating abortion provider, and then video chat with that provider. If appropriate, the provider can decide to dispense the medication to the patient’s address, and the patient can take it at home.

Under this system, women don’t have to travel several hours just to pick up the abortion pills, Erica Chong, director of Gynuity Health Projects, told POLITICO. The Gynuity study has enrolled about 360 people across eight states since 2016; it builds on recent research concluding that telemedicine-facilitated medical abortions are just as safe for patients as the ones administered in-person.

Because it’s been reviewed by the FDA, the Gynuity trial is exempt from the dispensation limitation. The study operates in Maine, New York, New Mexico, Hawaii, Colorado, Oregon, Washington and Georgia. Gynuity’s trial in Georgia began a few weeks ago, shortly before the state passed its “fetal heartbeat” law.

“With a lot of these bans, there’s going to be a long legal battle,” Chong said, explaining that she didn’t expect the new Georgia law, which bans abortion after a fetal heartbeat is detected at about six weeks, to affect the study in that state just yet. But she noted that the recent spate of early abortion bans have alarmed patients, who are unsure whether their appointments are still legal.

Gynuity’s goal is to convince the FDA that dispensing abortion medication directly to women’s homes, or even to retail pharmacies, is safe and effective, and that restrictions on its dispensation should be eased, Chong said.

Outside the Gynuity trial, some providers across the country let patients drive to the facility closest to them and video chat a clinician located at another site. Planned Parenthood, for instance, lets patients in 14 states virtually consult with clinicians based elsewhere. Yet in many cases, the clinician must watch the patient ingest the pill on screen to comply with federal restrictions limiting where the medication can be dispensed. Women might still have to travel across state lines to access these services — and many don’t even realize these options exist.

“How’s a woman in Alabama going to know to go to a Georgia clinic to find services?” Chong said.