Many state abortion bans include exceptions for rape. How often are they granted?

toggle caption Geoff Stellfox for NPR

After the Supreme Court overturned the federal right to abortion in 2022, many states that banned the procedure did so with the promise that it would still be legal in some circumstances, including in the event of rape. One study estimates that over 64,000 pregnancies have occurred due to rape in the years since the ruling in states where abortion is banned.

But many people on the front lines of this issue say getting an abortion in these states after an assault is difficult or — in some cases — impossible.

There is no central database that measures abortions performed because of rape. For this story, NPR looked at state records and talked with researchers, advocates and doctors in seven of the 11 states where abortion is banned but legal in the case of rape. Taken together, these accounts show a patchwork of laws governing rape exceptions, confusion over who qualifies for an exemption and law enforcement’s role in that process, and widespread fear from doctors about performing abortions for assault victims.

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Many victims aren’t capable of immediately reporting their rapes

It’s all but impossible to know exactly how many abortions are performed because of rape exemptions. When they report the procedure, doctors aren’t required to include a reason. And an abortion could fall under a different exemption — such as a fetal anomaly or life of the mother.

Existing annual data suggests that in many states, the numbers of known abortions performed due to rape are in the single digits or, in some cases, zero.

One reason for that is because in many states, rape victims who want an abortion are required to report their assault to law enforcement. Advocates and medical professionals who work with rape victims say in the aftermath of an attack, there are more immediate issues to consider than abortion laws.

“It’s just too much for them to manage at that point,” says Katy Rasmussen, a nurse who works with assault victims with the Johnson County Sexual Assault Response team in Iowa. The patients she sees are frequently in shock or dealing with the stigma around sexual assault. If alcohol or illegal substances are involved, Rasmussen says, patients may feel shame or even blame themselves.

“Often, sexual assault survivors just want it to be over,” says Kelly Miller, former executive director of the Idaho Coalition Against Sexual and Domestic Violence. “And so having to go through the trauma of reporting, the trauma of a forensic interview, most survivors opt out of all of that.”

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Other advocates point out that many patients are experiencing domestic violence when they are raped. That’s what happened to Laurie Betram Roberts. She says she became pregnant years ago after she was raped by someone she lived with. Reporting him and risking his arrest, she says, could have meant losing her housing.

“We shared a residence,” she says. “There was no domestic violence shelter that would take me because my family was too big.”

Bertram Roberts, who has seven children, did eventually disentangle herself from this man. She now works with people in similar situations as part of her job with the Mississippi Reproductive Freedom Fund, a nonprofit that helps people get abortion care in that state.

“There’s a perception of good and bad abortions” among people who defend state abortion bans, Bertram Roberts says. “But the truth is the exemptions are all rhetoric and no practical use.”

Last year in Mississippi, there were zero abortions for any reason, according to a recent report from The Society of Family Planning’s WeCount project.

Mississippi Gov. Tate Reeves promised exemptions for rape when the state’s 2022 law went into effect. NPR reached out to Reeves’ office as well as to lawmakers in multiple states who sponsored these bans and to national anti-abortion groups. None of them wanted to speak on the subject of rape exemptions across the country.

One group, Susan B Anthony Pro-Life America, sent NPR a written statement laying blame with doctors and health systems for their confusion and inability to utilize the law. “If there are doctors who are confused about rape exceptions, hospital administrations and health associations should provide clarity,” the statement read.

Some doctors say they feel weaponized and intimidated

Involving law enforcement makes patients and doctors feel like “potential criminals,” says Jessica Tarleton, an obstetrician in South Carolina, where by law, doctors must report abortions performed because of a rape to their local sheriff’s office.

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“Somebody comes into the emergency room who’s been shot, we don’t ask them what they did to be in a position to be shot. We take care of the patient,” says Tarleton. She points out that no other kind of medicine demands doctors legally justify care.

“In the past two years,” she says, “I am aware of one one patient that I was associated with that sought a legal abortion under the rape exception.”

Tarleton tries to offer abortion care whenever she legally can. But she says many doctors in this state are scared and feel they don’t have enough support to provide abortions in a place where it feels legally risky. As a result, she says, many distance themselves from the practice altogether.

“Now I’m the investigator”

Iowa makes it particularly difficult for rape victims to get an abortion, according to doctors and reproductive rights advocates.

This summer, after a long court fight, the state started enforcing a six-week abortion ban, which makes an exception for certain things like rape. But directions from the Iowa Board of Medicine say doctors — before performing an abortion – must determine whether a rape is legitimate or risk legal consequences for noncompliance.

toggle caption Geoff Stellfox for NPR

It’s an unusual level of detail for doctors to collect and document, even among the other 10 states that include exemptions for rape.

“Now I’m the investigator trying to decide if the details of the incident constitute rape as per Iowa Code,” says Dr. Emily Boevers, who works in Waverly, a town of 10,000 in northeastern Iowa. She says these requirements threaten the privacy, trust and intimacy of the patient-doctor relationship. “I’m supposed to maintain a therapeutic, caring relationship with this patient while I query all these details,” Boevers says.

So far, she hasn’t had to investigate the circumstances of assault with a patient, but she’s practicing what she’ll say when that day comes. “Unfortunately, our government mandates that I must ask you some questions,” she plans to say. “If you are able to answer these, I might be able to help you.”

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Those who enforce the laws might not always know the laws

In some states, there is little clarity on rape exemptions even among those officials charged with enforcing the laws.

Idaho outlaws abortion with exceptions for rape, incest and when the life of the mother is threatened. To get an abortion, sexual assault victims have to produce a police report for medical providers.

When the state’s ban went into effect in 2022, victim advocates quickly pointed out that law enforcement agencies don’t release police reports until a case is closed – preventing victims from accessing timely care. The following year, the Idaho Legislature amended the bill’s text so that rape victims are entitled to receive, upon request, a copy within 72 hours of the report being made.

But agencies appear to follow these requirements unevenly.

Boise State Public Radio reached out to 56 law enforcement agencies across Idaho about their protocols to assist rape victims since the ban. A handful said they complied with the 72-hour amendment and said their in-house victim advocates were available to help victims throughout their process.

Many others seemed unfamiliar with the amendment. Several public records departments said they would automatically deny requests for copies of a report on an open case, regardless of who made it. One agency realized it hadn’t been complying with the 72-hour law after it went into effect and had unknowingly denied records to rape victims.

Local agencies said they had received no guidance from the state.

Advocates say this murky process compounds a system of reporting that’s already unwelcoming to victims.

“Survivors generally don’t report to these systems that were never created to be centered around survivors in the first place,” says Miller, the former head of the Idaho Coalition Against Sexual and Domestic Violence. “It’s just unrealistic to expect that survivors will access these systems just for the purposes of being able to gain access to an abortion as a result of a pregnancy from a sexual assault.”

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State records suggest there were fewer than 10 abortions for any reason last year in Idaho.

Providers of rape-exception abortions often are shielded by big institutions

Only a handful of doctors interviewed for this story reported performing rape exception-abortions with any consistency. Those who did all worked at major academic medical institutions.

Dr. Nisha Verma in Georgia estimates she sees someone who has been raped or experienced incest who meets the exception standard “every couple weeks.”

Verma isn’t an official spokesperson and didn’t want to be identified using her institution’s name. But she says her employer has protocols and task forces to assist doctors in managing their legal risk. That helps mitigate doctors’ fears of losing their medical license, being fined or going to jail.

“At my institution, we have really again worked to create a system that helps us as doctors feel more supported and protected,” Verma says.

But for most people who work with victims, it’s not simply a question of how to get abortion exemptions. Some states, for example, are also constrained by a shortage of providers willing even to deliver babies, let alone perform legally risky procedures.

“The question is,” says Bertram Roberts of the Mississippi Reproductive Freedom Fund, “If you got an exemption in Mississippi, who’s going to perform your abortion?” The state has a significant shortage of obstetricians.

Bertram Roberts says she’s never seen anyone in that state get an exemption — for any reason, let alone rape.

In this Feb. 22, 2025 photo provided by Pro-Voice Project founder Jen Jackson Quintano, Quintano is pictured (R to L) with abortion storyteller Desi Ballis and Dr. Amelia Huntsberger, an OBGYN who once practiced in rural Idaho but has since moved to Oregon. Courtesy Jen Jackson Quintano

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Abortion is illegal in Idaho, which borders Oregon to the east. For years leading up to the U.S. Supreme Court’s Dobbs decision overturning Roe v. Wade, women’s health advocates warned that maternal care and abortion services were part of an intrinsically woven set of OB/GYN care that women’s health depended on. Now that Idaho has outlawed abortion – the state’s ban is among the most restrictive in the nation – residents are living out what advocates predicted. Some women who want to have children can now no longer get maternal care where they live , and some have suffered complications during pregnancies they desperately wanted to take to term but could not, because of their own health or fetal anomalies.

Jen Jackson Quintano lives in North Idaho with her husband and two children and runs a tree service business. She began a storytelling effort she calls the Pro-Voice Project , for women to tell their own stories about accessing – or not being able to access – reproductive health services. The project has held live performances mostly around Idaho for women to tell their own stories at the microphone. In some cases when they haven’t felt comfortable speaking publicly themselves, their stories are performed by actors.

Desi Ballis and her husband lost their third child, Tucker, a year ago , in the second trimester when the couple discovered he had a fatal condition. Ballis, who lives in Haley, Idaho, was at risk of life-threatening complications before she made it to Utah to have a medically necessary abortion. In Idaho, she would not have been able to get that care until she was actively dying.

Ballis and Quintano join us to share their personal experiences and what they hope to achieve by sharing some of the most painful experiences of their lives. Members of the Pro-Voice Project will be in Portland Saturday, March 1 for an event that highlights women’s stories Idaho and in Oregon, where women face no state restrictions on abortion, but some still struggle with other barriers to access.

Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.

Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. After the U.S. Supreme Court overturned the constitutional right to an abortion in its Dobbs decision, Idaho enacted one of the most restrictive abortion laws in the country. It’s meant that some women who want to have children can no longer get maternal care where they live. Others have suffered complications during pregnancies they desperately wanted to take to term, but couldn’t because of their own health or fetal anomalies. That’s in addition to women who want to terminate their pregnancies but can’t do so in their home state. Jen Jackson Quintano lives in North Idaho. She started the project with a simple idea that there is power and value in hearing all of these stories. She calls her effort the Pro Voice Project. She joins us now along with Desi Ballis, a mother and educator who has told her own story as part of this project. Welcome to you both.

Jen Jackson Quintano: Thanks for having us.

Miller: Jen, first, what made you decide to start Pro Voice?

Jackson Quintano: It was really, it was related to the Dobbs decision, of course. I think a lot of us were impacted by that. I just felt an enormous amount of anger when that decision came down and I think a lot of times beneath anger, we find that there’s grief. And that was certainly the case for me thinking about my past experiences with not having a say over my body and decisions around my body and my sexuality, and just the thought of that sort of cultural experience now being the law of the land. It was too much and I felt like I just needed to do something. And stories are the best way I know to advocate for issues, to reach people, to connect, to build empathy. So I just started collecting stories and it’s really expanded from there.

Miller: As I mentioned, Desi is one of the women whose stories you have collected, as you say. Desi, my understanding is that you and your husband had two kids already when you got pregnant in 2023. As you said in a video that Jen produced, you were thrilled, you’ve been trying for a while, for a third. How far along were you in that pregnancy when you learned that there was some kind of problem?

Desi Ballis: Yeah, so I actually got pregnant in February of, I was pregnant in February of 24, so it was just this past year and I was around 20 weeks. I went for my anatomy scan, and that was when we had found out that our son, Tucker, was really sick. And so by the time we had fled the state and got the care that we needed, I was 21 weeks.

Miller: Before you, as you say, fled the state, what did your doctor in Idaho tell you and as importantly, I suppose, what didn’t he tell you?

Ballis: It was a really nuanced conversation. He just continued to tell me that it was so important that I got to Utah. He had already contacted doctors there for me and they were going to be calling me within minutes to follow up. What I was not told was that I needed an abortion. I just kept having this emphasis that I needed to get out of state and that my baby was very sick. And then right before I left was just this really firm kind of redirective, like, I need you to really understand your baby is not going to survive. Because it went from trying to fix the situation to then, how do we then take this on?

Miller: What might have happened if you had simply stayed in Idaho?

Ballis: Well, I guess the reality is that I might not be here today, because doctors are so fearful to act, and they don’t know when to act, based on the current legislation. I would have had to have been significantly far along in either sepsis or losing blood, or any other kind of infection before doctors could legally act to support me and help me.

Miller: Was your doctor able to even say that to you, that if you don’t go and have an abortion in a state where you can, you might die in our state? Could he say that?

Ballis: No, not at all. In fact, I think that was his driving force for just being so firm. He grabbed my hands and just told me multiple times and looked me dead in the eye and just kept saying over and over and over again, “I need you to get to Salt Lake. I need you to get there. Do you understand this? This is very serious. I need you to get to Salt Lake.” And of course I didn’t know at the time what I truly needed. I thought it was strange, but I was listening to my doctor with full trust.

Miller: What happened when you got to Salt Lake?

Ballis: Yeah, so once I got to Salt Lake, I had a full team waiting for me, which was wonderful. We went through a myriad of additional tests and screenings, and everything had kind of confirmed what we had learned in Idaho, with this added piece that now my son had progressed rapidly just in this 24 hour period. And because I have Idaho-based insurance, I was not able to get care in the hospital. And so we were weighing financial options of $20,000 to $30,000 to stay in a hospital, going to different clinics, finding a clinic that could even get us in, weighing all of our options: do we wait, do we act fast? How sick am I going to get? How quickly am I going to get sick? It was just this very fast tracked myriad of impossible decisions.

Miller: How did you decide to tell your story?

Ballis: I feel like the first couple of months, I really couldn’t even put into words what had happened to me. And I just remember thinking this is such an injustice and also how naive of me as a woman, when you hear abortion laws and you hear, oh, there’s exceptions for the health of the mother, you think that of course, if I need this, I can get it, and I was so ignorant. And I just thought to myself, how many other women out there just don’t know and could potentially endure what we went through? And then it just shifted my whole perspective of I can’t just let my son pass and have gone through this without speaking out and now making this my mission to make sure it doesn’t happen to others.

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Miller: Jen, what has it been like to get women in Idaho to tell their stories about seeking abortions?

Jackson Quintano: Oh gosh, it’s, it’s difficult. I mean, on so many levels. This is not something that we are accustomed to talking about, as is the case with a lot of things related to reproductive health care. We don’t often talk about miscarriages. We don’t talk about abortions. We are, there’s a lot of shame around this, or stigma, so there’s trying to get beyond that barrier. And also there’s the fact that people in Idaho are quite fearful when it comes to speaking up, just in general, but especially with issues like abortion. There is a concern like, oh, if I talk about this, could there be legal consequences for me? Could I get in trouble? There’s that, there’s also the sense of, if I speak up and share that I had an abortion, what will happen to me? Will there be threats to me, verbally, physically? Will my community ostracize me? What will happen? There is a lot of fear in the state around these sorts of things, and we just, we don’t know what to expect when we speak up.

So it’s been a lot of working through fear and working through shame to just get people to feel comfortable saying the word abortion and then moving into storytelling about it. And one thing that’s been really helpful is the bravery of people like Desi. I mean, my heart is full of so much gratitude to her and others like her who are brave and coming forward with their stories because then it creates a safe space for other people to do the same. Bravery begets bravery. So the more stories we collect and we share, the easier it is to have this conversation.

Miller: Desi, did you have those fears that Jen has just outlined?

Ballis: Oh, absolutely. I would say I still do. Yeah, I identify as a Christian woman. We live in a very, very small town. My husband is an elected official. I mean, we have every microscope possible on us and our family. And I still feel like that gives me even more of a responsibility to speak out and share this truth and this reality that so many women are going through these days. I just feel this real strong responsibility with that, regardless of the fear and that is very real.

Miller: Have you gotten pushback from people in your life, or strangers, since you started telling your story?

Ballis: It’s been overwhelmingly positive, but of course those negatives sit in the back of your mind and replay, especially coming from a Christian world. There’s a lot of opinions on abortion. And yeah, some of the responses have just been downright cruel and just awful.

Miller: Would you have described yourself as pro-life before you went through this?

Ballis: Not necessarily. I truly believe that as a Christian, it is not my place to push my beliefs on anyone else. My only calling as a Christian is to love others and love on them. And God gave us free will. And I would say that I never was pro-life or pro-choice. I just felt the need that women, in their own space and in their own world, should have the right to decide. And I never really thought of the nuances of medical complications and fatal fetal anomalies, of course as much as I know now, unfortunately, but yeah, I was not a hard line on that like most Christians are.

Miller: The Pro Voice project is gonna be taking part in an event at the First Unitarian Church of Portland this Saturday at 3 p.m.

Jen, how much do you see your effort now as a response, not just to the overturning of Roe and the changes in state laws around the country that have followed, but changes in response to the way that abortion had been talked about in the decades that preceded that Supreme Court case? I guess I’m wondering how much you want stories about abortion themselves to change in the public consciousness.

Jackson Quintano: Yeah, that’s a great question. I look back at the era where Roe was the law of the land, and we didn’t talk about abortion when it was illegal. As I mentioned before, that resided in the realm of shame, stigma, silence. It was something that a lot of people availed themselves of, but they didn’t feel comfortable sharing that fact with others in their life. And the rights that you’re not talking about, you’re not fighting for, and those rights tend to slip away. And I think we didn’t do ourselves any favors in not talking about the place that abortion has held in our individual lives, and within the realm of medicine too. We just, we’ve sort of siloed it from the rest of the reproductive health care experience.

And so, of course, I would like to see a change in the laws as soon as possible, but I also see the work that I’m doing as like the slow cultural change to bring these stories into the public consciousness. To elevate these stories, to expand the narrative, so it isn’t just this black and white, this binary, without any nuance. I want there to be a lot of nuance in this conversation and just understanding for all the reasons why someone might need abortion care and to normalize use of the word, to normalize its discussion, because it is a very important part of healthcare, as we heard from Desi’s story. Let’s hope we can change some of these laws soon and turn this ship around, but also let’s do the work on the ground as a culture to create more space for this experience that so many of us need to seek out.

Miller: Who do you most want to reach with the events that you put on or the videos that you produce?

Jackson Quintano: So recently I held an event in a small community south of Sand Point where I live, and we had about 30 people show up for it. It was a screening of some of our short documentary films. One of the films is about Desi and her experience, and the room was a mix of people, but there were a large number of people there who considered themselves pro-life. And that was really powerful to be able to share space with people on both sides of this issue, to have them hear stories from the mouths of people who have been impacted by these laws and then to have a conversation about it face to face. When you’re looking into someone’s eyes, it’s a lot harder to bring vitriol to the conversation, or participate in name calling and so we were able to have a very lovely nuanced conversation about the abortion experience.

And people in the room were willing to say, I consider myself pro-life, and I don’t want to impose my views on someone else. The stories I saw today were tragic. I wouldn’t want someone to have to go through that. Or someone can say, I’m pro-life, and more than that, I don’t want government reaching into anyone’s healthcare decisions. And so it was nice to have a room full of people who could hold both experiences and talk about it with one another, and disagree with one another, but at the end of the night, be able to hug before departing. And so that right there feels like a real win to me, to be able to enter those spaces.

Also, that said, I don’t want to dismiss what we call preaching to the choir. We tend to denigrate that is like less than, but especially here in Idaho, it is so important to rally those who do support abortion rights and help them feel like they’re not alone in that, that it’s OK to speak up about that, that they have safety in numbers, we’ve got their back. And engage them in this fight, so they can overcome their fear to fight for this.

Miller: Desi, what do you most want people to know about the full repercussions of Idaho’s abortion ban?

Ballis: Yeah, I feel like my big ‒ and this really has just been evolving over the last year as I go through this journey ‒ it’s just this idea that fatal fetal anomalies and the need for life saving healthcare doesn’t discriminate. They don’t care if you’re pro-choice, pro-life, what political side you land on, Christian, atheists, wherever you fall within your faith, even. These things don’t discriminate, and the need for health saving life care is critical, and you cannot legislate every nuance of pregnancy. It is such a complicated thing and imposing your belief system on someone else that restricts them from life, their own life. I just want to bring that perspective forward, and help people see it from another view.

Miller: Desi and Jen, thanks very much.

Ballis: Thank you.

Jackson Quintano: Thank you for having us.

Miller: Desi Ballis is one of the women who has participated in the Pro Voice Project, which encourages women to tell their stories about accessing healthcare after Idaho’s abortion ban was enacted. It was started by Jen Jackson Quintano.

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Dr. Daniel Christie wears a pin on his white coat that says “Vote.”

He doesn’t want to get into politics with his patients, but he does want them to know he believes his job is on the line with Amendment 4 on November’s statewide ballot, which would enshrine a right to abortion in the state constitution.

“If I can convince one patient coming through my clinic, ‘Hey, you know what? My rights, my daughter’s rights, my sister’s rights, they’re on the ballot this year. I’m going to vote. Then, you know what? Good,” said Christie, an OB-GYN in Broward County who specializes in infertility.

Since May 1, when the Heartbeat Protection Act went into effect, some OB-GYNs in Florida say they are nervous to provide care that the state insists is legal under the law. The state generally prohibits, with exceptions, abortions after six weeks of pregnancy.

Amendment 4 would restore allowing abortion in Florida up to “fetal viability,” usually around 24 weeks. If it doesn’t pass, providers told the USA TODAY Network-Florida that women will take dangerous risks to end their pregnancies.

How do they know? Because it’s already happening, they say.

The six-week prohibition may as well be an outright ban, said abortion rights advocates, since many women do not know they are pregnant at six weeks. Anti-abortion supporters of the Heartbeat Protection Act argue that defending unborn life is a moral responsibility of the state, and detecting a heartbeat is a significant milestone that signals the presence of a distinct human life.

“If this passed, you would be able to have six months old, in the womb, a fully-formed baby, heartbeat, can feel pain, sucking its thumb, you see it on the ultrasound, you see the face, and that would be able to be snuffed out for no reason, whatsoever,” said Gov. Ron DeSantis at a press conference surrounded by doctors in Jacksonville recently.

However, only 1% of abortions happen after 21 weeks, according to data from Pew Research Center.

Exceptions to the current abortion law include “fatal fetal abnormality” and rape, incest and human trafficking. While the state clarified that most of those exceptions have a cut off for 15 weeks, the state’s health care agencies do not say whether that applies to “fatal fetal abnormality.”

The state has not yet charged a doctor for providing an abortion, but that doesn’t mean much to Dr. Alexandra Levy, who says ambiguity in the laws and current legislation in other states that potentially puts doctors at risk leaves legal departments advising “just do absolutely nothing, because you don’t want to risk the wrath of an attorney general.”

Aside from the moral and religious factors in the abortion debate in Florida, health care providers already are saying – some publicly but most privately – that they’re caught between patients and their legal risk managers. They’re fearful that honest decisions about the best care may land them as defendants in lawsuits or worse – charged with crimes.

“We’re all afraid. We’re losing faith,” Levy said.

Doctors pile onto petitions on both sides of debate as DeSantis digs in

Florida’s Agency for Health Care Administration and Department of Health have made clear that providers will not be criminally charged and an abortion is allowed at “any stage of pregnancy” to save the life of the mother.

The agencies also have said that the law does not include criminal penalties for women who get an abortion.

But some doctors and patients see hardline laws taking shape in other states and DeSantis’ fusillade of attacks against Amendment 4, and they worry.

Even with multiple attempts to reach providers, many would not even speak to the USA TODAY Network – Florida under anonymity because they feared repercussions from the state, their employers or both.

Elected officials in other states, like Idaho and Missouri, have attempted to pass legislation that would criminally charge women who get abortions or who help women travel to get one.

In 2023, Missouri lawmakers filed bills that would charge a woman with homicide on behalf of a victim who is an “unborn child at every state of development from the moment of fertilization until birth,” one of the bills stated.

The measure was later withdrawn, but providers in Florida wonder if a bill like that could be next.

“Nobody deserves to go to work and worry, ‘Is this the day that I get accused of murder and dragged out of here in handcuffs?’ ” said Levy, who has been practicing in Florida for two years.

Dr. Tamberly McCarus, an OB-GYN with Florida Physicians Against Amendment 4, disagrees and said Florida’s law is “not ambiguous in any shape or form.” She does not believe the Heartbeat Protection Act will lead to more extreme laws.

DeSantis has hosted a number of press conferences with doctors across the state, including McCarus, to condemn the ballot initiative.

The governor has pushed back hard against Amendment 4 since the beginning: fighting the amendment’s existence in Florida’s Supreme Court; hiring outside consultants to help craft a fiscal impact statement on the ballot; investigating the authenticity of the ballot initiative’s petition signatures; and sending cease and desist letters to TV stations threatening criminal charges if they didn’t stop running pro-Amendment 4 ads.

DeSantis and opponents to Amendment 4 argue the ballot measure’s authors are “lying” to Floridians, and words used, like “health care provider” and “viability” leave too much room for “outsiders” and unqualified practitioners to come to Florida and perform unsafe procedures.

But the terms they call into questions are defined in state law. “Viability” is defined as “the stage of fetal development when the life of a fetus is sustainable outside the womb through standard medical measures.” A “health care provider” must be licensed by the state.

Florida Physicians Against Amendment 4 boasts over 700 physicians’ signatures who say the ballot measure would “usher in a substandard of care, and undermine their ability to care for women and girls,” but a spokesperson declined to release the full list of names to a reporter. Seventy of those physicians, 10%, are OB-GYNs, according to Prudence Robertson, a spokesperson for the group.

And just 130 physicians of the more than 850 who have endorsed Amendment 4 are OB-GYNs, according to a list provided by the Yes on 4 campaign – or roughly 15%.

Lawsuit emerges to pull amendment from the ballot as some doctors fear for future in Florida

On Oct. 16, a lawsuit was filed to pull Amendment 4 from the ballot. Alan Lawson, a former Florida Supreme Court justice and lead counsel for the plaintiffs, described as “four concerned Florida voters,” is alleging Amendment 4’s sponsor and elections officials illegitimately certified the measure for placement on the 2024 ballot.

Two of the plaintiffs are a woman who survived an abortion attempt and another woman who said she was coerced into getting an abortion.

“I was pushed by my boyfriend into an abortion I didn’t want, and the abortion industry was eager to provide it. Tragically, my experience is far from uncommon,” plaintiff Lorien Hershberger of Taylor County said in a press release from Lawson.

“For years I’ve worked with lawmakers on pro-life efforts to protect babies and moms; I won’t stand by and watch proponents of Amendment 4 use fraud to push an unpopular and extreme abortion policy on Floridians to erase all we’ve done,” she added.

Christie said to limit abortion based on gestational age is “offensive” to women, as abortions at or after 21 weeks are rare and make up 1% of all abortions in the U.S. Moreover, 96% occurred at or before 15 weeks gestation, while 3% occurred from 16 to 20 weeks gestation, according to health policy research group KFF. The state’s previous ban, which went into effect in July 2022, kicked in at 15 weeks.

“These are not folks who wake up at 36 weeks and say, ‘You know what? … I’m just gonna terminate. I don’t think I really want to do this,’ ” Christie said. “These are unbelievably complex and tragic circumstances for the mother, for the fetus, or for both that have to be dealt with in the most horrific of circumstances.”

Cherice Felix, an OB-GYN at Planned Parenthood in West Palm Beach, said she left Tennessee after the state banned abortion and “watched that system fall apart piece by piece.”

“Each restriction, each ban, it opened the door to a new way of restricting communication between doctors and their patients in the exam room,” she said during a Zoom press conference for the Yes on 4 campaign. “It restricted the care that we could give our patients, and then eventually it just flat out banned it. So I now live and work here, and watching similar things happen here in the state of Florida, it’s really alarming.”

Five states, including Tennessee, have either enacted or are considering “abortion trafficking” laws. Such laws typically allow for criminal charges on an adult who is found to be “recruiting, harboring, or transporting” a minor to get an abortion, according to an Idaho law that was the first to go on the books.

In October, the Texas Supreme Court let stand a lower court decision that says hospitals are not required to provide emergency abortions.

Cases like this, along with the stories of two Georgia women whose deaths were linked to the state’s abortion ban, are frightening providers and especially patients, who have more questions now that they have fewer options.

“They are hearing wild and crazy things on social media, some of which are absolutely true,” said Cheryl, a midwife who practices in North Florida, who asked to remain anonymous because of fear of professional repercussions.

During a routine third trimester checkup, one of her high risk patients came to her appointment with her husband and looked her in the eye and asked, “How are you going to decide if I have to die in order for the baby to live?”

Cheryl was stunned. “I said, ‘We’re taking the best care of you and your baby,’ ” she said, grateful it never came to that.

But critics of the amendment say such concerns are overblown.

Dr. Christina Peña, a Miami OB-GYN also with Florida Physicians Against Amendment 4, said at a Coral Gables event with DeSantis, “Do not believe the lie. Women are not dying across our state because of lack of access to abortion under our current laws.”

Few Florida options for women seeking abortions beyond six weeks

For women in Florida who don’t qualify under the exceptions and who seek to get an abortion after six weeks, there are few options. If the fetus’ gestational age is lower than 11 weeks, they can get abortion pills, mifepristone and misoprostol, through the mail.

“It’s better than the coat hanger days, but still, I wouldn’t want my daughter to take mifepristone unmonitored,” said Christie. These medications “are about as safe as you can get, but like any medication, there’s complications, so I would want supervision.”

Beyond 11 weeks, the pills may not be effective and could increase complications, Christie said. But women may still take the risk. Some already are.

“Did abortions happen prior to 1973? Of course, they happened. Did they happen completely safely? No, they did not. And that’s where we are at this point. We’re pre-1973,” said Christie.

That year, the U.S. Supreme Court determined the U.S. Constitution protected a women’s right to an abortion in Roe v. Wade. The current court tossed out that decision in June 2022, throwing the issue to the states.

Now, if a woman wants to travel for an abortion, she will have to spend thousands of dollars to get to Washington, D.C., or New York City, some of the closest places that allow abortion with the fewest barriers.

While North Carolina allows abortion up to 12 weeks, the 72-hour in-person waiting period makes it difficult for many to make the somewhat drivable distance for an appointment.

The next closest is Virginia, where abortion is banned in the third trimester. But it’s hard to find direct flights, the nearest abortion provider can be an hour from the airport and those clinics are already at capacity.

As previously reported by the USA TODAY Network-Florida, four out of the five organizations that provide monetary assistance for those seeking abortions in Florida say they have seen drastic increases in the number of callers and costs since May 1.

After abortion, some Florida doctors worry IVF is next

The way Christie talks about his patients is with a fierce defensiveness. He says they’ve already been through enough by the time they see him for fertility treatment, like in-vitro fertilization.

Which is where he thinks the state is going to go next if Amendment 4 doesn’t pass. “There’s no question. IVF is on the menu,” he said.

Here’s why: Some doctors worry that “heartbeat” bills could potentially affect embryos for IVF. For example, three states, including Georgia, have already enacted fetal personhood laws. In Georgia, the 2022 LIFE Act states that ” ‘unborn child’ means a member of the species Homo sapiens at any stage of development who is carried in the womb.”

And earlier this year, Alabama’s Supreme Court ruled that frozen embryos are legally protected as children, which shut down IVF clinics across the state and rushed that state’s legislature into fast tracking a law to backpeddle the decision.

McCarus, who opposes Amendment 4, said she doesn’t believe Florida will go “extreme” and outlaw IVF, however.

“Cooler heads and medical scientists probably prevailed in that (Alabama) decision, so I’m actually relieved that that happened,” she said.

Yet earlier this year, a fetal personhood bill, Civil Liability for the Wrongful Death of an Unborn Child (SB 476), was filed by Sen. Erin Grall, R-Fort Pierce, the sponsor of the Heartbeat Protection Act. The bill, which never made it out of the Florida Senate Rules Committee, defined “unborn child” as “a member of the species Homo sapiens, at any stage of development, who is carried in the womb.”

This September, the governor’s Faith and Community Initiative hosted an event with Attorney General Ashley Moody and Mat Staver, the founder and chairman of the Liberty Counsel, called “Your Legal Rights & Amendment 4’s Ramifications.”

When the Alabama legislature passed the IVF protection law, Staver called it a “knee-jerk reaction.”

“It is too bad legislators are moved more by political winds than in science and in the fundamental issues involving human life,” Staver said. “Every human life begins as an embryo and has incalculable worth. Yet this law presents a double standard treating IVF embryos differently by removing their legal protections.”

Every day, Christie has at least one patient who asks him if their embryos are safe in Florida, and their worries aren’t unfounded, he said.

“I’m out of the game of guessing what this current Legislature is capable of. Because if you’d asked me two years ago, three years ago, would this be a conversation I would ever be having? Absolutely not,” he said.

Ana Goñi-Lessan, state watchdog reporter for the USA TODAY Network – Florida, can be reached at agonilessan@gannett.com.

Abortion bans still leave a ‘gray area’ for doctors after Idaho Supreme Court case

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The Supreme Court’s abortion ruling on Thursday is a narrow one that applies only to Idaho and sends a case back down to the appeals court. Confusion among doctors in states that have strict abortion bans remains widespread.

The case concerns the kinds of situations in which emergency room doctors could end a pregnancy. Under Idaho law, it is a felony to provide nearly all abortions, unless the life of the mother is at risk. But what if a pregnancy threatens her health? For now, those abortions can happen in Idaho emergency rooms.

“Essentially what we got is not true relief to people in Idaho or in other abortion-banned states,” says Dr. Nisha Verma, an OB-GYN in Atlanta. “There is continued uncertainty, in terms of what is going to happen in the future.”

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The federal government has a law known as the Emergency Medical Treatment and Active Labor Act – or EMTALA – which says that anyone who comes into the emergency room must be stabilized before they’re discharged or transferred. The Biden administration argued that should apply, even if the treatment is an abortion, and the patient is in a state that bans abortion with very limited exceptions. The court, in a 6-3 vote, dismissed the case, without ruling on its merits.

Verma notes that the court did not establish that EMTALA is the standard across the country.

‘Life of the mother’ exceptions

Idaho is one of six states that have abortion bans that do not include exceptions for the health of the mother. The other states are South Dakota, Texas, Oklahoma, Arkansas and Mississippi, according to KFF, the health policy research organization.

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By sending the ruling down to the lower court, the decision allows Idaho doctors the go-ahead to treat pregnancy complications in the E.R. again, but possibly only until the Ninth Circuit Appeals Court rules in the case. It offers no such instruction in the other states with strict bans.

Idaho Attorney General Raúl Labrador said he was optimistic about the appeals court. “The Ninth Circuit’s decision should be easy,” he said in a press conference following the decision. He was confident the Idaho law would prevail. “I remain committed to protect unborn life and ensure women in Idaho receive necessary medical care.”

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Labrador said he has been in touch with doctors and hospitals across the state, and acknowledged doctors were fearful of prosecution. “As long as [doctors] are exercising a good faith judgment that the condition could lead to death, that [a patient’s] life could be in jeopardy, even if it’s not immediate, they can perform the abortion.”

The Justice Department, which brought the case against the state of Idaho was also optimistic. “Today’s order means that, while we continue to litigate our case, women in Idaho will once again have access to the emergency care guaranteed to them under federal law,” Attorney General Merrick Garland said in a statement. “The Justice Department will continue to use every available tool to ensure that women in every state have access to that care.”

Muted relief for an Idaho OB-GYN

Dr. Sara Thomson, an OB-GYN in Boise, was a panelist with Health Secretary Xavier Becerra at an event on reproductive rights on Wednesday when Becerra’s press secretary shared news of the decision that had accidentally been posted on the Supreme Court website.

“I didn’t have my phone with me for the duration of that event, and I walked out of the building and had 42 text messages about all of this,” Thomson says. “I’m starting to weed through and process it. Initially, of course, I was relieved when I saw the headline, but my relief has been muted in learning that this may just be another temporary decision.”

For now, she and other OB-GYNs in Idaho have more clarity and legal security when they treat patients facing early pregnancy emergencies, she says, adding that those are always devastating conversations.

“I am relieved for the patients that I’m going to be taking care of in the immediate future. I do still feel like it’s tragic that pregnant women have had to languish with emergency complications and have their care delayed or denied while our state fought this and the Supreme Court took six months to consider the case,” Thomson says.

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Idaho’s abortion law has also made a shortage of doctors in the state worse. Nearly one in four OB-GYNs have left the state or retired since the law went into effect, according to a recent report, and hospitals have been having trouble recruiting new doctors. Three hospitals closed their labor and delivery units in Idaho.

Disappointment all around

Advocates and experts on both sides of the issue expressed frustration and disappointment that the Supreme Court didn’t address the substance of the issues in the case.

“We urge the courts to affirm the availability of stabilizing emergency abortion care in every single state,” Dr. Stella M. Dantas, president of the American College of Obstetricians and Gynecologists, wrote in response to the decision. “We are truly disappointed that this decision affords no long-term clarity of the law for doctors, no comfort or peace of mind for pregnant people living under abortion bans across the country, and no real protection for the provision of evidence-based essential health care or for those who provide that care.”

“The Supreme Court created this health care crisis by overturning Roe v. Wade and should have decided the issue,” wrote Nancy Northup, president and CEO of the Center for Reproductive Rights, which has filed state lawsuits representing dozens of patients who claim abortion bans harmed them. “Women with dire pregnancy complications and the hospital staff who care for them need clarity right now.”

Dr. Ingrid Skop, an OB-GYN and director of medical affairs at Charlotte Lozier Institute, a research organization that opposes abortion, was also disappointed in the outcome. “Forcing doctors to end an unborn patient’s life by abortion in the absence of a threat to his mother’s life is coercive, needless and goes against our oath to do no harm,” she wrote in a statement. Her organization wrote a brief in support of Idaho’s case.

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A case about the ‘gray area’

Patient stories that have come out since Roe v. Wade was overturned in June 2022 have illustrated the conflicts that can arise during pregnancy complications in states with very limited abortion exceptions.

Jaci Statton, a 27-year-old in Oklahoma, had a partial molar pregnancy last year — a type of pregnancy that is not viable. Despite being too nauseous to eat and at risk of hemorrhage, hospital staff would not give her an abortion. She lived too far from the hospital to wait at home.

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Oklahoma Children’s Hospital staff “were very sincere, they weren’t trying to be mean,” Statton told NPR last year. “They said, ‘The best we can tell you to do is sit in the parking lot, and if anything else happens, we will be ready to help you. But we cannot touch you unless you are crashing in front of us or your blood pressure goes so high that you are fixing to have a heart attack.’” She later filed a federal complaint against the hospital, but it was rejected.

Reached this week, Statton explained that before she found herself in need of an abortion during a pregnancy complication, she didn’t know that could happen. “I’ve always been pro-life — I didn’t even know there was a gray area that existed,” she says. “A lot of people, and especially in the more conservative states, I don’t think that they know there is a gray area. I think they think it’s very black and white. It’s either good or it’s bad. I think a lot of people should be educated more about these types of things,” like molar pregnancies, ectopic pregnancies, and serious genetic fetal anomalies.

She said state lawmakers dismissed what happened to her, which makes her angry. “Oklahoma is a very proud state that they’re abortion free, and I’m like, ‘Yeah, that’s really like good for a pro-life [state] but at what expense to the people in need?’”