As Iowa's 'fetal heartbeat' abortion ban looms, clinics prepare for an uncertain future

In the final days before one of the most restrictive abortion bans in the country is expected to take effect, the atmosphere at Iowa abortion clinics has become emotionally fraught.

This week marks a dramatic legal and policy change in the reproductive care permitted in the state. But even as health care providers prepare for this new uncertain reality, what they say they dread the most are conversations that are personal, intimate and searing – speaking with individual women who come to them seeking care.

“Us telling them we can’t see them might mean they have to stay pregnant. And that’s a really difficult and emotional conversation between staff and patients, but it’s one we’re going to have to keep having,” said Dr. Abbey Hardy-Fairbanks, medical director of the Iowa City-based Emma Goldman Clinic.

Enforcement of the so-called “fetal heartbeat” ban is expected to begin as early as Friday after the Iowa Supreme Court ruled last month that an injunction against the law should be lifted. The law bans most abortions after fetal cardiac activity can be detected, typically at about six weeks of pregnancy – before many women know they’re pregnant.

The previous law, which is still in effect until a Polk County district court judge formally receives the decision later this week, currently allows the procedure up to 20 weeks of pregnancy.

The majority of abortions happen after six weeks of gestation, according to data from the Centers for Disease Control and Prevention for 2021. Forty-nine percent happened from seven to 13 weeks’ gestation and 7% at 14 weeks or later, while 45% were obtained at six weeks or earlier.

Across the state, abortion clinics are working to provide what care they can in the final days before the six-week ban goes into effect. In the leadup to the Iowa Supreme Court’s June 28 decision, staff worked longer days, added more appointments to the calendar and otherwise did what they could to fit in as many patients as possible, physicians said.

“On a personal level, it just felt like a cloud was hanging over our heads,” said Kristina Remus, Minneapolis, Minn.-based patient services associate with Planned Parenthood North Central States. “Sometimes, it's hard to do business as usual when you know that something like this is happening, and obviously our patients have been feeling that as well. They definitely feel anxious about their ability to access abortion now and in the future.”

More: 6-week abortion ban can take effect, Iowa Supreme Court rules, ending injunction

Clinics, nonprofit vow to continue care in complicated legal landscape

Even as they work to see remaining patients under the current 20-week abortion law, clinics are planning for a future when access to abortion care is severely restricted. Abortion providers have vowed to continue abortion care – albeit, on a much more limited capacity.

According to the Guttmacher Institution, about 4,200 abortions were provided in Iowa in 2023, which includes medication and surgical abortions. That's an 18% increase from the 3,510 abortions performed in 2020.

In the hours after the state’s highest court issued its decision last month, Planned Parenthood North Central States and the Emma Goldman Clinic said their organizations would continue to provide abortion care to some degree once the law goes into effect.

That commitment has not waned in the days since.

“At the Emma Goldman Clinic, we plan to remain present and here and providing abortion care within the limits of the law as long as we possibly can,” Hardy-Fairbanks said. "While the injunction remains in place, we are just trying to get as many patient seen as we can and make some logistical plans for the future.”

Planned Parenthood North Central States, which includes Iowa, echoed that sentiment.

"At no point are we going to turn away patients," said Erin Wagner, senior director of strategic communications for Planned Parenthood North Central States. "We are trying to find different ways to help them. So after the ban is enacted, we will still continue to help Iowans access abortion care in Iowa before cardiac activity as indicated. If patients are trying to schedule appointments for abortions and they're going to be past that threshold, we'll be working with them to help them schedule appointments across state lines."

Physicians inside Iowa’s abortion clinics say they are still working to understand how they can provide that care within the confines of the law and developing contingency plans to see patients as quickly as possible within the six-week window. Physicians say their organizations are essentially starting from scratch to create that process for patients.

Clinics also are still grappling with questions on how to offer abortions under the law’s narrow exceptions for rape, incest, fatal fetal anomalies and to save the life of the mother.

Physicians say they still lack clarity from the rules written and approved earlier this year by the Iowa Board of Medicine, the state body enforcing the law. As a result, physicians will likely need to rely on attorneys or hospital administrators to make decisions on when to provide an abortion.

“That means that when you're in that medical emergency, you have to think carefully and build a lot of consensus around whether the Board of Medicine or (Iowa Attorney General) Brenna Bird is going to agree with me that this was a medical emergency. That’s going to be a huge time suck when, literally, people’s lives are on the line," said Dr. Emily Boevers, an OB-GYN who had provided abortion care for Planned Parenthood until earlier this year.

But even with this planning, Boevers said the ramifications of such a restrictive law will mean many Iowa patients will be unable to access that care.

“There's no amount of opening extra clinic days or having extra staff that's going to make up for all the patients that on July 20 are going to have their rights rolled back," Boevers said.

The Iowa Abortion Access Fund, which helps Iowans access abortion care that they might otherwise not be able to afford, will continue to offer resources to Iowans under the new law, said Lyz Lenz, a board member of the organization. The group provides grants to cover the cost of abortions as well as any travel expenses, such as the cost of a hotel.

Recently, the organization partnered with the Chicago Abortion Fund to help manage requests for funding from Iowa.

“We just felt like it was the way to just continue continuity of care, partnering with a fund that was not under threat," Lenz said. "We wanted to just make sure that Iowans continue to have the help that they need.”

Lenz said the group anticipates a major influx in requests for funding in the coming months. So far in 2024, the organization has seen a 7% increase in requests for funding from the previous year. The access fund reported a 27% increase after the U.S. Supreme Court overturned the 1973 Roe v. Wade decision, which guaranteed a constitutional right to abortion nationwide.

Some abortion providers look to other states to plan for the future

As clinics work this month to enact plans, they say this effort has been part of their reality since well before the Iowa Supreme Court ruling.

Since 2018, Iowa’s Republican governor and GOP lawmakers have been working to ban abortion once embryonic cardiac activity could be detected. In that time, the state’s top elected officials also created laws to mandate a 24-hour waiting period and counseling prior to an abortion, policies meant to limit the procedure in the state.

While officials at Iowa's remaining abortion clinics say they are prepared to navigate a more precarious legal landscape, some advocates express concerns about whether health care providers can continue abortion care to a meaningful degree. They raise concerns about clinics' ability to recruit a maternal health care workforce under the ban, as well as other potential ramifications reported by other states with strict bans.

“I am highly concerned that there will be significantly less access to abortion in Iowa," Boevers said.

Knowing further restrictions were possible, Planned Parenthood has spent recent years establishing regional care and otherwise expanding access to services in states surrounding Iowa, Wagner said The organization often highlights its work with patient navigators, who help patients find appointments and the resources to pay for expenses around receiving an abortion.

As Planned Parenthood officials prepared for the ban, Wagner said, they spoke with their counterparts in Texas, which passed a similar ban in 2021. Much of their emphasis will focus on educating patients about their ability to access abortion care under these bans, to counter what Wagner described as "manufactured chaos" from politicians passing these laws.

"One of the things that we did learn was that patient behavior did change, and people started to understand that they needed to get in earlier," Wagner said. "So the hope is that over time, folks will understand that we're working within the six-week ban."

The Emma Goldman Clinic will continue to provide other reproductive and primary health care services, even as the staff grapple with the new reality, Hardy-Fairbanks said. Though recent events have taken an emotional toll on the staff, she said, they remain dedicated to serving the community.

“We all hope that this isn’t the forever law of the land, but I think in Iowa, it’s going to be here for a while," she said.

Michaela Ramm covers health care for the Des Moines Register. She can be reached at mramm@registermedia.com, at (319) 339-7354 or on Twitter at @Michaela_Ramm.

This article originally appeared on Des Moines Register: As 6-week Iowa abortion ban looms, clinics report tension, uncertainty