Last summer, Gov. Eric Greitens summoned Missouri legislators to Jefferson City for a special session with the sole purpose of considering new regulations on abortion clinics.
Out of that session came tighter controls on a procedure that in Missouri had become the most common method of terminating a pregnancy in the early stages: medication-induced abortion.
The law has effectively banned medication abortion in Columbia, Joplin and Springfield, leaving Kansas City and St. Louis as the only options for the procedure. It’s also prompted multiple lawsuits as clinics that perform abortions work to get it overturned.
And now — six months after the regulations went into effect — the battle continues to be waged in courtrooms in Jefferson City and Kansas City.
Two Planned Parenthood groups — Comprehensive Health of Planned Parenthood Great Plains and Reproductive Health Services of Planned Parenthood of the St. Louis Region — are pushing for a preliminary injunction to block the law, which they say is causing "irreparable harm" to the clinics and their patients and imposing an undue burden on women's right to choose abortion. They’re squaring off in federal court against the Missouri Attorney General’s Office, which is representing the state.
Both sides presented testimony at hearings earlier this month and filed additional briefs in the case this week.
"Medication abortions are incredibly safe, with less than 1 percent of patients experiencing major complications," the Planned Parenthood groups said in a statement to The Star. "These stringent requirements are not imposed on any other medical service in the state, including medications and surgeries with far higher complication rates."
But the state argues that the law put in place "common-sense regulations" that protect women and ensure they will have access to adequate care in case of medical emergencies.
"The regulation promotes women's health and safety in numerous, material ways," it said in a recent court filing, adding that the benefits of the regulation "outweigh any minimal burdens on access." Medication abortions, the state said, are nearly six times as likely to result in a complication as first-trimester surgical abortions.
Medication abortion was approved by the U.S. Food and Drug Administration in 2000 and is available only in the first 10 weeks of pregnancy. The procedure involves a combination of two pills — mifepristone and misoprostol. One pill is taken in the clinic and the second is taken 24 to 48 hours later, most often at the woman's home, causing a process similar to a miscarriage.
While some think medication abortion is the same as what's known as the "morning-after pill," that's not the case. The "morning-after pill" is an emergency contraceptive that is taken within 72 hours of having unprotected sex to prevent a woman from getting pregnant, while medication abortion ends a pregnancy.
In 2014, medication abortions accounted for 45 percent of abortions nationwide before nine weeks gestation, according to the Guttmacher Institute, a nonprofit research organization that supports the right to abortion. Since the procedure was approved, Planned Parenthood says, more than 3 million women in the United States have safely had a medication abortion.
A woman currently can obtain an abortion in three cities in Missouri — Kansas City, St. Louis and Columbia. Planned Parenthood's St. Louis center provides both medication and surgical abortion, the Kansas City clinic offers only medication abortion, and the Columbia center provides only surgical abortion.
Planned Parenthood has been trying to obtain approval from the state Department of Health and Human Services to provide medication abortions at its clinics in Columbia, Springfield and Joplin but says the new law has thwarted its efforts.
One section in the law requires clinics to get approval of a "complication plan" that meets DHSS requirements. The DHSS regulations prohibit medication abortion services unless providers obtain written contracts with two ob-gyns who have local hospital admitting privileges and who agree to be on call 24 hours a day, seven days a week to treat complications from medication abortion.
Planned Parenthood says the regulations are unnecessary and unfairly single out abortion procedures.
"This requirement is imposed only on providers of medication abortion, the most common method of terminating an early pregnancy among Missouri women, and not on any other medical service in the state, including medications and surgeries with far higher complication rates," the Planned Parenthood groups said in a recent court brief.
The organization said it has tried to comply with the new regulations by reaching out to every ob-gyn in the Columbia, Springfield and Joplin areas, but none was willing to enter into an agreement.
"These efforts were entirely unsuccessful, and given the political climate around abortion in Missouri and in these communities in particular, were exercises in futility," the Planned Parenthood groups said.
When one former abortion provider in Springfield was contacted, Planned Parenthood said, the doctor told them he could not help because "Springfield is just a different kind of community and I need to not be associated with Planned Parenthood anymore."
Another ob-gyn said he feared retribution if he got involved: "I have been doing this work for nearly 40 years and had a colleague shot to death for providing abortion care."
As a result, Planned Parenthood said, Missouri is limited to two medication abortion providers at opposite ends of the state. Because of that, women in central and southwest Missouri must travel hundreds of miles — making two trips because of the state’s three-day waiting period — to obtain a medication abortion, the groups said.
Planned Parenthood said not a single patient's care will be improved by the regulation.
"In the rare event that a medication abortion patient has a complication that requires follow-up care, such complications occur after the patient has left the health center and returned home," the organization said.
That means patients would receive the care at home, "from exactly the same doctors who would have provided it if they were permitted to have their medication abortion at the health center near where they live," Planned Parenthood said.
The need to travel also will cause some women unnecessary delay and expense, Planned Parenthood said. Others will be forced to undergo a more invasive surgical abortion, it said, "and still other women are forced against their will to continue their pregnancies to term."
But state Solicitor General John Sauer recently argued that the request for a preliminary injunction should be denied and the lawsuit dismissed. Among the reasons given: Planned Parenthood had failed to make a good-faith effort to comply with the regulation and could not prove that the regulation presented a significant obstacle to the majority of women seeking medication abortions.
"The regulation does not pose a substantial obstacle to a large fraction of women because there is no constitutional right to medication abortion, and the regulation does not affect surgical abortion," the state said in a recent court brief.
Planned Parenthood has "greatly overstated" the burdens that the regulation places on women seeking abortions, the state argued.
"Plaintiffs' evidence rests on the assumption that all women will travel hundreds of miles to obtain a medication abortion instead of obtaining a safer surgical abortion nearby," the state said in its brief filed Monday.
The lawsuit is the second to be filed by Planned Parenthood challenging the new law. In the other case, filed in Jackson County, the groups asked the court to block a portion of the law that requires that the same physician providing an abortion must inform the patient of the medical risks three days before the procedure.
A Jackson County Circuit Judge found that the provision did not impose an undue burden on women seeking abortions, and it is on appeal in the state circuit court.
Missouri hasn't always required facilities providing medication abortions to have a license. That changed in 2007, when legislators passed a law requiring abortion providers to be licensed as ambulatory surgical centers and doctors to have local hospital admitting privileges.
In 2016, after the U.S. Supreme Court struck down a similar measure in Texas, the Planned Parenthood groups in Missouri sought a preliminary injunction to stop enforcement of those parts of the Missouri law. The injunction was issued in April 2017, and Planned Parenthood announced it would begin providing abortion services in four Missouri locations. But the state was successful in getting the injunction suspended, and that case is now on appeal. Meanwhile, Greitens called the special legislative session to enact new regulations on abortion providers.
As both sides wait for the court's decision, it's unclear when the case will ultimately be resolved. But it may not be any time soon.
Once the court rules on whether to block enforcement of the law while the case moves forward, more appeals are likely. And the lawsuit itself isn’t scheduled to go to trial until March 2019.