Commentary Abortion

As Susan Cahill Faces a Vandalized Clinic, a Reminder of Her Contribution to Abortion Access

Carole Joffe

By now, many have heard about the horrific vandalism that recently took place at Susan Cahill's clinic in Montana. But what some people may not know is that Cahill was one of the pioneers in bringing advanced practice clinicians (APCs) into abortion care, thus expanding abortion access in underserved areas.

By now, many in the abortion rights community have heard about the horrific vandalism that recently took place at All Families Healthcare in Kalispell, Montana, the family medicine practice of Susan Cahill, a physician assistant (PA). Cahill includes abortions as one of numerous services offered to her patients and this clearly was the reason for the attack. As reported at Rewire and elsewhere, Cahill’s clinic was completely destroyed and remains closed as of this writing. Less well known, however, is Cahill’s important role, more than 20 years ago, in a consequential event in U.S. abortion care history—an event that continues to resonate today.

In the late 1980s, staff at the National Abortion Federation (NAF) began to hear increasing concerns from member clinics about their difficulties in finding doctors to work at their facilities. (The number of abortion providers peaked in the United States in 1982.) Terms like the “graying of abortion providers”—referring to the cohort of committed abortion doctors who had witnessed the pre-Roe era and were nearing retirement age—and “provider shortage” entered the lexicon of the abortion rights community. In response, NAF, along with the American Congress of Obstetricians and Gynecologists (ACOG), organized a symposium called “Who Will Provide Abortions?” which took place in October 1990 in Santa Barbara, California. The symposium, dominated by physicians both associated with NAF and other, more mainstream medical groups, resulted in a number of important initiatives, including the founding of a postgraduate fellowship program in abortion and family planning and the establishment of requirements for abortion training in OB-GYN residencies.

One of the most significant events that occurred at that symposium was the participation of Susan Cahill from Montana and Rachel Atkins, also a PA, from Vermont. The peculiarities of laws in their respective states permitted abortion provision by PAs, and both these women had amassed an impressive safety record by 1990. Cahill, who had been trained in abortion care in her PA program right after Roe, had worked since 1976 with James Armstrong, a family physician in private practice in Kalispell, while Atkins worked at the Vermont Women’s Center, a (now closed) facility that provided a full spectrum of reproductive health services. Both women presented at the symposium, which this writer attended, and made an enormous impression on the attendees. In a highly unusual move for that time, given normal medical politics and hierarchies, the published report of the symposium stated that “appropriately trained midlevel clinicians … offer considerable promise for expanding the pool of abortion providers” and recommended training for certified nurse midwives, nurse practitioners, and physician assistants. (The term “midlevel clinicians,” which was in use then to refer to these three groups, has been largely replaced by “advanced practice clinicians” [APCs].)

The argument for the entrance of these health-care providers into abortion care received a further boost at a second symposium organized by NAF in Atlanta in 1996, which was focused specifically on APCs as abortion providers, and where Atkins and Cahill played a leading role. Since those two meetings, a number of medical organizations—including ACOG, the American Public Health Association, the American Academy of Physician Assistants, the American College of Nurse Midwives, and the National Association of Nurse Practitioners in Women’s Health—have issued statements in support of abortion training and provision by APCs.

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Susan Cahill, along with her colleague and friend Rachel Atkins, was a pioneer in bringing APCs into abortion care, and thus in expanding access to the procedure in underserved areas. Currently, according to NAF, APCs are providing medication abortion in 15 states and aspiration abortion in six. Indeed, one of the few current bright spots in the beleaguered abortion providing world, at this time of unending states restrictions—the recent passage in California of legislation allowing APCs to provide aspiration abortion (they already were permitted to perform medication abortion)—can be seen as a legacy of the revolution that Cahill, Atkins, and their allies started some 20 years ago.

Cahill has now provided abortions—both medication and aspiration—in Montana for nearly 40 years, continuing on her own after James Armstrong retired. Anti-choice politicians in her state have made concerted efforts to stop her abortion practice, at one point passing a law specifically targeting her. The Montana Supreme Court eventually upheld her right to provide abortions.

The recent destruction of Cahill’s clinic was not her first encounter with domestic terrorism. In 1994, the office she shared with Armstrong was firebombed (and eventually rebuilt).

The model of care Cahill has offered all these years—the integration of abortion with primary care—is exactly the vision many have had of how to respond to the reproductive health needs of women in rural communities. Abortions, she told me, represent about 10 percent of her practice. As Cahill wrote in an opinion piece in her local paper after the vandalism:

I have performed health care services for 38 years. I have patients who have been coming to me for that long. I have seen their parents and their children. I provide first trimester abortions AS PART OF THAT SERVICE because I know that the same women who at one time in their life want and are joyful about being pregnant, may, at another, find themselves unable to bring a child into the world. That crisis used to cause them their lives. The truth is that abortions are very simple and safe procedures that most medical professionals, especially those who are trained in women’s medicine, can and should do.

The destruction of Cahill’s facility not only imposes further hardships on women in the region, who now must make a trip of several hours to access safe abortion care—the vandalism also deprives, at least for the time being, the three generations of locals for whom she has been providing primary care. These patients, men and women, are also casualties of the abortion wars. As Cahill wrote to me, speaking of anti-choice terrorism, “When will this ever stop?”

Investigations Violence

As Threats Spike, Advocates Urge Feds to Strengthen Law Protecting Abortion Clinic Access

Sofia Resnick

Just two days after NARAL Pro-Choice America submitted a letter asking the U.S. Department of Justice to investigate anti-choice activities as domestic terrorism, an extremist opened fire on a Planned Parenthood clinic in Colorado, murdering three people and injuring nine others.

On a frigid January afternoon this year, a day before the 43rd anniversary of Roe v. Wade, about a dozen fresh-out-of-college feminist campus organizers marched the halls of Congress after divvying up a list of representatives to visit.

Smartly dressed under bulky winter coats, organizers Kelli Musick and Chelsea Yarborough, who work for the national nonprofit the Feminist Majority Foundation (FMF), dropped by the office of Rep. Marsha Blackburn (R-TN).

Blackburn chairs the House of Representatives’ Energy and Commerce Committee’s Select Investigative Panel, created last October principally to investigate Planned Parenthood. The panel formed after the anti-choice front group the Center for Medical Progress (CMP) released a series of heavily edited videos in which it claimed—though never proved—that Planned Parenthood was illegally selling fetal tissue.

As part of their mission that day, Musick and Yarborough left written materials with a staffer asking Blackburn to either redirect her panel’s focus to violent attacks on abortion clinics, or to dissolve it. Specifically, the FMF wanted the congressional panel to investigate the leaders behind CMP, whose rhetoric has fueled a recent spate of threats and attacks against abortion providers, the foundation’s president, Eleanor Smeal, told Rewire in an interview. Though the investigative scope of the panel is actually quite broad, it does not specifically include abortion clinic violence as an area to probe.

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But in the four months since Musick and Yarborough submitted their request to Blackburn’s staff, the panel has forged ahead with its investigation, not just into Planned Parenthood’s fetal tissue donation practices, but into abortion practices generally. This week, House Democrats requested that Speaker Paul Ryan (R-WI) disband this panel, arguing that it amounts to little more than a biased, expensive witch hunt on fetal tissue researchers and abortion providers.

Really, though, the FMF’s mostly symbolic ask is part of a recent, ongoing push by abortion rights groups to demand that the federal government start taking violence and threats aimed at abortion providers more seriously. National organizations last year began identifying a spike in violent acts, such as arson, vandalism, and death threats, directed at reproductive health clinics and staffers.

NARAL Pro-Choice America started a campaign last November asking the U.S. Department of Justice (DOJ) to investigate these types of activities as domestic terrorism. Just two days after NARAL submitted its letter to the federal agency, an anti-choice extremist opened fire on a Planned Parenthood clinic in Colorado murdering three people and injuring nine others.

This rise in threats and attacks—further documented in a report published last month by the National Abortion Federation (NAF)—has also prompted abortion rights groups to demand that the government strengthen and fully enforce the Freedom of Access to Clinic Entrances (FACE) Act, a 22-year-old federal law intended to ensure access to abortion clinics and to protect the lives of abortion providers and patients.

“The time for us being quiet is over,” Smeal said at a news conference held in January. “We are determined that we are going to bring the anti-abortion violence issue to the forefront of decision making.”

A Call for More FACE Investigations

The FACE Act, which allows for criminal and civil remedies, makes it a federal crime to use force or the threat of force to prevent people from accessing or providing reproductive health care. For example, the law bans the destruction of clinic property and the practice of blocking someone’s entrance into a clinic.

Before President Bill Clinton signed the FACE Act in 1994, some abortion foes would travel the country and barricade themselves in front of clinic doors. Such blockades came to be known as “operation rescue,” pioneered by the national group of the same name whose current president, Troy Newman, was involved in the aforementioned video campaign targeting Planned Parenthood.

“It’s called ‘interposition,'” Rev. Rusty Lee Thomas told Rewire in a phone interview. He said that this blockading practice is based on a biblical and historical concept, where “someone stands in the gap between the sort of tyrant and its victim.” Thomas said in this case, the doctors providing abortions were the tyrants and the aborted fetuses the victims.

Thomas now runs a group called Operation Save America. Back in the 1990s, he joined anti-choice activists in these ventures. But Thomas said he gave up this particular brand of protest after the DOJ sued him and others under the FACE Act in 1998, after he had attempted to block the entrances of reproductive health clinics in multiple cities in Ohio. Though the federal government ultimately dropped the charges, the threat of prison time and hundreds of dollars in fines ended his blockading days, Thomas said.

“Like anything else, when the price tag goes up, people really do have to weigh that,” he said. “By that time, the government was successful at scaring people and shutting it down. The tactic of ‘operation rescue’ was put to an end.”

Many abortion rights supporters agree with Thomas that the FACE Act curbed clinic blockades. They say this federal policy and similar state laws helped decrease violent attacks, such as clinic bombings and murders of clinic workers and doctors. Smeal said that, according to the FMF’s frequent clinic surveys, the year the FACE Act went into effect, more than 50 percent of abortion clinics reported experiencing violence; today that number has dropped to 20 percent.

Since 1994, the DOJ has filed a total of 27 civil FACE cases in 17 states, a Justice Department spokesperson told Rewire in an email. The spokesperson said the DOJ receives “a great deal of information” from national abortion provider groups, as well as from victims, local law enforcement, and media reports.

As Rewire has reported previously, both criminal and civil prosecutions under FACE tend to fluctuate based on which political party controls the White House: During President George W. Bush’s administration, for example, criminal prosecutions under the FACE Act declined by more than 75 percent to about two a year, compared to an average of ten prosecutions a year under the Clinton administration. During President Obama’s first term, the DOJ reported prosecuting 11 criminal cases under the FACE Act, charging 12 defendants.

During a Senate Judiciary Committee hearing in March on the oversight of the Justice Department, Attorney General Loretta Lynch testified that her agency increased criminal prosecutions and civil cases filed under the FACE Act within the “past five or six years.” But she did not give the total number of cases prosecuted under the act. She estimated that under the Obama administration, the DOJ has charged a total of 12 criminal cases criminally and nine civil ones.

Advocates and providers say these figures pale in comparison to the number of acts of violence and harassment annually committed against clinics and providers nationwide.

Since the NAF began tracking abortion clinic violence in 1977, the organization reports that as of 2015, there have been 185 arsons, 42 bombings, 26 attempted murders, and 11 murders, three of which occurred last year.

Advocates are currently waiting to see whether the government will bring a FACE complaint against Robert Lewis Dear Jr., who invoked anti-abortion animus upon arrest and during his first media interview after he admitted to shooting up the Colorado Springs Planned Parenthood clinic last November. During her testimony in March, Lynch said the DOJ is reviewing “a possible FACE Act violation” against Dear while his murder case proceeds in state court.

It appears, however, that this case will be in limbo for a while. Earlier this month, a judge ruled that Dear lacks the mental competency to stand trial, after forensic psychologists diagnosed him with a delusion disorder they claim is based on the accused shooter’s fringe political beliefs, among them that federal agents are spying on him. Dear, meanwhile, has been very clear that he does not want to plead insanity; rather, he wants to argue that the attack on Planned Parenthood was legally justified because he was fighting against the greater evil of abortion. For the time being, Dear will be treated at a state psychiatric hospital until, if ever, he is deemed competent to stand trial.

In any case, it might seem unnecessary to charge Dear with a federal felony crime of obstructing access to abortion when he’s already on trial for multiple murders. But some advocates say that charging these crimes under FACE is important symbolically because, as with hate crimes, the FACE Act helps draw the link between crimes like vandalism, arson, and murder, and a specific bias against a group of people. Being able to illustrate a pattern of anti-abortion crimes is necessary in order to bring awareness to law enforcement and the public and to potentially deter anti-choice extremists from threatening or committing acts of violence, they say.

It’s for this reason that physician assistant Susan Cahill wanted to bring a FACE claim against Zachary Klundt, who destroyed her All Families Healthcare clinic in Kalispell, Montana, in March 2014, forcing her to forever shutter her clinic.

According to testimony that surfaced during the sentencing hearing, Klundt had texted his mother hours before the break-in, asking her for information about the “abortionist,” and had told a psychiatrist evaluating him after the break-in that Cahill was a “murderer.” Notably, Klundt’s mother sat on the board of the anti-choice pregnancy center that purchased Cahill’s old building and evicted Cahill.

Yet despite this circumstantial evidence, Klundt testified that he smashed all of Cahill’s medical equipment and personal photos and poured iodine on her patients’ medical records because of serious drug addiction, not anti-abortion animus.

“Even though everybody knows why he did it, legally it wasn’t tried that way,” Cahill told Rewire.

Though third parties can bring civil suits under the FACE Act, Cahill said she likely would be unsuccessful trying to use the statute in this case, because Klundt was only found guilty of vandalism and the court did not make a specific finding about his motivations in committing this crime.

Instead, she is suing Klundt, his family, and the crisis pregnancy center that forced her from her old building, for negligence, nuisance, and “intentional infliction of emotional distress.” She said she hopes that if the case moves forward, discovery proceedings will surface what she suspects were Klundt’s anti-abortion motivations.

To be sure, not all anti-choice activists and abortion clinic protesters escalate to violence. And abortion opponents like Susan B. Anthony List national campaign chair Jill Stanek say the FACE Act goes too far in regulating the actions of protesters. Stanek told ​Rewire​ that most of these activists peacefully exercise their free speech rights to protest what they believe is a form of murder.

As an example, Stanek pointed Rewire to a FACE claim in 2010 in which the DOJ sued an activist in West Palm Beach, Florida, accusing her of blocking the flow of traffic at an abortion clinic while she tried to give pamphlets to a couple in a car. A federal judge dismissed the claim as baseless.

Stanek argued that it is a political strategy among abortion rights supporters to “play up” acts of anti-choice violence and threats. She added that abortion opponents also receive their share of attacks and threats, including herself. Upon returning from vacation in late January, Stanek said she found a brick thrown through her window with a note reading: “Quit the pro-life bullshit.” Her local newspaper in Mokena, Illinois, reported the alleged incident. Stanek posted photos she says depict the brick and busted window to Facebook.

While Stanek maintained that most abortion protesters organize peacefully and called people like Dear part of the “lunatic fringe,” she did concede that protesting in front of abortion clinics is, in part, an attempt by her movement “to stigmatize abortion doctors.” The goal is also, she said, to convince patients to turn away from clinics and for clinic staff to quit their jobs.

It’s this stigma and endless, sometimes hostile, presence in front of reproductive health clinics that, abortion providers told Rewire, can help breed eventual violence. But Stanek said the movement is not about to abandon this crucial aspect of their multi-pronged strategy to end legal abortion.

“As far as we’re concerned, the last front, the last place that we have a chance to save a baby is at the abortion clinic,” Stanek said. “Laws haven’t worked, pregnancy care centers haven’t worked, educating hasn’t worked. Now we have the mom going into the abortion clinic. And so that is what compels certain people to go to abortion clinics and try to get women to change their minds.”

Abortion Rights Advocates Say FACE Is Weak on Threats, Harassment

It was lunchtime during the summer of 2012 when Dr. Willie Parker walked outside of Jackson Women’s Health Organization in Jackson, Mississippi. It was his first day at the clinic, which happens to be bright pink and the last standing abortion clinic in the whole state. As such, it’s a regular fixture for protests.

As he walked to and from a nearby sandwich shop, Parker said he was accompanied by a protester who “berated” him the entire way. He felt intimidated and threatened.

Parker, who currently divides his time among six clinics in five states, told Rewire in a phone interview that the FACE Act is a “mixed bag,” arguing it does not fully protect providers, especially when they are not on clinic property. He added that abortion foes have learned all of the federal and local statutes to know how close they can physically reach patients and providers while staying inside the law.

“At what point am I out of the safety created by [the FACE] Act simply because I chose to walk across the street from an abortion clinic to get a sandwich?” he said.

Many abortion providers think FACE is a relatively weak law, particularly when it comes to harassment and threats made against them, an element of clinic violence many advocates say is often ignored at the federal level. Though it forbids “the threat of force,” such a provision is open to interpretation by the courts.

Drexel University law professor David Cohen, who co-authored a recent book about anti-abortion terrorism, told Rewire last year that the FACE Act should be amended to specifically include stalking and harassing abortion providers within the law’s current definition of “intimidate.” Additionally, Cohen recommends directing the courts to assess threats from the perspective of an abortion provider, and increasing penalties.

Threats to providers have drastically increased in the last year, say advocacy groups. They attribute this increase, in part, to the incendiary rhetoric that Planned Parenthood “sells baby parts,” a recurring mantra from the Center for Medical Progress’ smear campaign against the reproductive health-care network.

The NAF tracked 94 threats of direct harm in 2015, compared to just one threat in 2014. According to its latest report, NAF hired an outside security firm in mid-November last year to track online threats, which helped to identify more than 25,000 incidents of hate speech and threats within six weeks.

Meanwhile, researchers at FMF also witnessed a sharp rise in threats against abortion providers last summer. Smeal said researchers were so concerned that they postponed a clinic violence survey that they were prepping to come out earlier this year and instead tried to help clinics prevent threats from escalating into actual attacks.

“We were very, very concerned about the increasing level of threats,” Smeal told Rewire in an interview. “Most of us who have been involved in this for a long time thought it was one of the highest threat levels we’ve ever seen. We were waiting for the violent acts to occur.”

They didn’t have to wait long.

Dr. Savita Ginde, the medical director at the Planned Parenthood clinic in Colorado Springs, was one of the doctors featured in one of CMP’s videos. After the video streamed online, Ginde allegedly received online death threats, as well as picketers outside of her home. In November, Dear was arrested for shooting up her clinic, declaring afterward, “no more baby parts.” Ginde was not harmed.

The connection of threats to violence worries advocates like Smeal. Extremists do not always act on their threats, but they sometimes do, she said. Or they create a climate that motivates someone to act out what the crowd is cheering for.

It’s for this reason that the reproductive rights community eagerly anticipated the recent trial in the Justice Department’s civil lawsuit against abortion foe Angel Dillard in the hopes that the result might strengthen future enforcement against threats under FACE.

In fact, the opposite might have happened.

The DOJ sued Dillard in 2011 after she mailed a letter to family practitioner Dr. Mila Means. Means was, at the time, training to perform abortions in Wichita to fill the gap left by Dr. George Tiller, whom Scott Roeder murdered two years earlier, admitting it was because Tiller performed abortions. In the letter, Dillard, who has ties to Roeder, told Means that thousands of abortion opponents across the country were monitoring her movements and that should she begin offering abortions, she should take care to check beneath her car for explosives every day “because maybe today is the day someone places an explosive under it.” In the letter, Dillard also referenced Tiller speaking to Means from hell.

The agency interpreted this letter as a threat of violence that violated the FACE Act. Means ended up not opening an abortion practice in Wichita. She told Rewire after the trial that she backed out, in part, because of the cultural and political climate against abortion in Kansas. “The threats work,” she said.

This climate was evidenced in the Wichita jury’s decision reached earlier this month. While the eight jurors did conclude that Dillard’s letter constituted a “true threat” not automatically protected by free speech, they also accepted Dillard’s attorneys’ arguments that her threats were religious in nature rather than violent.

“The letter was intimidating, but it was a more spiritual threat, a more emotional threat,” Adam Cox, the presiding juror, told Rewire in an interview following the verdict.

Thus, they found the letter did not violate the law and did not warrant civil damages or a protective order to keep Dillard away from Means.

Smeal said she was disappointed by the verdict in the Dillard case.

“It just shows you how hard it is to enforce this law,” she told Rewire in a phone interview.

Smeal said she is working behind the scenes with other advocates and lawmakers on efforts to eventually expand and strengthen the FACE Act. In the meantime, she said, law enforcement at all levels should be employing other existing laws to prosecute but also try to prevent violent attacks against abortion providers.

Some advocates, for example, have called on the federal government to treat demonstrated acts of anti-abortion violence, bomb threats, or murder as domestic terrorism.

Since NARAL launched its campaign last fall demanding that the DOJ begin investigating anti-abortion violence as domestic terrorism, NARAL Vice President of Policy Donna Crane said her group has seen more congressional members speaking out about abortion clinic violence as domestic terrorism.

“We think [the campaign] has raised important questions about why all too often anti-choice violence at women’s health centers is seen somehow as different, maybe even somehow a little bit more acceptable,” Crane told Rewire in a phone interview. “We believe that it’s just another flavor of domestic terrorism, and it should be talked about as such and treated as such.”

Smeal said her organization is similarly not backing down from its campaign asking the House committee investigating Planned Parenthood to take to task the activist groups that have, she believes, contributed to a dangerous climate for abortion providers and their patients.

Already, Smeal said, supporters have sent the committee thousands of emails as part of this campaign. And though she said it is difficult to know what effect the FMF’s campaign has had so far, she said she knows congressional members are listening.

Earlier in May, House Minority Leader Nancy Pelosi and the committee’s ranking Democratic member Rep. Janice Schakowsky held a press conference asking Speaker Paul Ryan to disband the House select committee, arguing that its investigation is putting access to reproductive health care as well as the lives of doctors and fetal-tissue researchers in danger, a point Smeal’s group has been making for months now.

“We’re going to keep it up, because we’re worried [the committee is] endangering health-care providers,” Smeal said of her group’s campaign. “We want to continue to shed light on this anti-abortion violence and basically are doing that in every way we can.”

News Abortion

Abortion Clinic Closures Reach ‘Dramatic’ Levels, Report Shows

Teddy Wilson

Since 2011, clinics have closed in 35 states home to a combined population of 30 million women of reproductive age.

At least 162 clinics that provided abortion services have either closed or stopped offering the procedure since 2011, with 21 clinics opening during that time, according to a report by Bloomberg.

The clinics have closed in 35 states home to a combined population of 30 million women of reproductive age. Bloomberg compiled the data over a three-month period, building on a similar report from 2013.

Texas was home to the most clinic closures. At least 30 abortion clinics have closed throughout the state, twice as many as any other state.

Iowa has seen at least 14 clinics shuttered, Michigan has seen 13, and California has seen 12 clinics close since 2011.

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Abortion clinics can close for a variety of reasons, but according to reproductive rights advocates, a spate of anti-choice laws are the driving force behind the clinic closures. These are known as targeted regulation of abortion providers (TRAP) laws. 

Elizabeth Nash, senior state issues associate at the Guttmacher Institute, told Rewire that numerous clinic closures are due to anti-choice activists pushing state lawmakers to pass measures making it impossible for many clinics to operate. 

“Unfortunately the report shows that abortion access is becoming more and more limited and that restrictions do have a direct and negative impact on access,” Nash said. “As we see more restrictions, the climate in a state becomes more hostile to abortion, which makes it harder to keep clinics open.”

Laura McQuade, president and CEO of Planned Parenthood of Kansas and Mid-Missouri, told Rewire that the clinic closures are reaching “dramatic proportions.” Missouri is one of five states that has only one abortion clinic, as anti-choice state laws have closed all but the Planned Parenthood St. Louis clinic.

These closings disproportionately affect marginalized populations. “Laws like these impact women across the board, but impact rural women, lower-income women, and women of color in dramatically intensified ways,” McQuade said.

Further, Missouri’s 72-hour forced waiting period requires patients seeking abortion care to make multiple visits to the clinic, and for patients traveling long distances this can pose significant burdens, including getting time off of work, arranging travel, and paying for child care.

Sylvia Cochran, who operates two clinics in Louisiana, told Rewire that many clinics are closing around the country because of the rash of anti-choice policies pushed through Republican-majority legislatures.

“These regulations have been imposed on clinics, and many of them are imposed [by lawmakers who know] that they cannot meet the requirements,” Cochran said.

Those regulations, pushed by GOP legislators, include medically unnecessary measures that require abortion providers to secure admitting privileges at a local hospital.

Former Louisiana Gov. Bobby Jindal (R) in 2014 signed into law HB 388, an omnibus anti-choice bill that contained multiple abortion restrictions, including a requirement that physicians that provide abortion services obtain admitting privileges at a nearby hospital.

Reproductive rights advocates have challenged the Louisiana law, but the U.S. Court of Appeals for the Fifth Circuit ruled last week that the law could take effect during the legal challenge. While advocates have asked the U.S. Supreme Court to immediately block the law, the decision has forced two of the state’s remaining four clinics to stop providing abortion services.

Cochran’s Delta Clinic in Baton Rouge has stopped providing abortion services, and patients are being referred to the Women’s Health Care Center in New Orleans. The physician who provides abortion services at the Delta Clinic does not have the admitting privileges required by the GOP-backed law.

The Hope Medical Group for Women in Shreveport is the only other clinic providing abortion services in the state. Reproductive rights advocates say the lack of clinics creates significant barriers for people seeking legal abortion care. 

Cochran says that patients around the state who do not live in the New Orleans or Shreveport areas will be forced to drive long distances to terminate a pregnancy, and make two visits to the clinic in order to satisfy the state’s forced counseling requirement.

The Women’s Health Care Center has already seen an increase in the number of patients due to the recent closure of another clinic, the Causeway Medical Clinic in Metairie. “We have seen an increase in our patient load,” Cochran said. “We have had to add two more days.”

The clinic now provides abortion services four days a week.

Those seeking abortion services already must plan the procedure taking into account their work schedule or child-care needs, but the increased patient load makes appointments more difficult to schedule. “It makes it difficult for patients when they come because there are longer waits,” Cochran said.

While anti-choice state laws have been the primary reasons for most clinic closures, clinics that have been the target of terroristic attacks have also been forced to close. In most cases they have been able to reopen.

The Planned Parenthood health-care center in Pullman, Washington, where a firebombing in September destroyed much of the facility, and the Planned Parenthood clinic in Colorado Springs, where a shooter killed three people in November, both reopened in February.

The All Families Healthcare, a family medicine and reproductive health-care facility in Kalispell, Montana, closed after being vandalized by an anti-choice activist. Susan Cahill, the owner of the clinic, has since closed the clinic indefinitely.