Delayed and Denied: How Florida’s Six-Week Abortion Ban Criminalizes Medical Care

Executive Summary

In June 2022, the U.S. Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization overturned the federal constitutional right to abortion.[1] In July 2022, Florida enacted a ban on abortion care after 15 weeks of gestation from the first day of a pregnant person’s last menstrual period, with only limited exceptions.[2] Two years later, in April 2024 the Florida Supreme Court followed suit and overturned decades of precedent that the Florida Constitution’s Privacy Clause protects the right to abortion. This judgment cleared the way for a new, far more restrictive six-week abortion ban to take effect on May 1, 2024.[3] This ban shifted the legal limit for abortion from 15 weeks to six weeks from the first day of a pregnant person’s last menstrual period and included only very narrow exceptions that differed from those in the 15-week ban. The penalties for those who violate the ban are severe, including imprisonment, fines, and loss of medical licenses.[4] On the same day that the Florida Supreme Court revoked state constitutional protection of abortion rights, however, it also allowed a proposed amendment that would enshrine abortion rights into Florida’s Constitution to be included on the state’s November 2024 ballot for voters’ consideration.

Florida’s extreme abortion ban has created an unworkable legal landscape that endangers both patients and clinicians. The ban violates individual reproductive freedom, leads to preventable suffering, and compels clinicians to deviate from established standards of care and medical ethics. These denials constitute violations of Floridians’ fundamental rights, including their human rights to life, health, privacy, freedom from torture and cruelty, and equality.

In July and August 2024, PHR researchers conducted in-depth, semi-structured interviews with 25 reproductive health care clinicians and clinicians in training in Florida about their experiences caring for pregnant patients under the six-week ban. In these interviews, clinicians stated that while abortion clinics in the state continue to provide care where legally permitted, Florida’s six-week ban is creating insurmountable barriers to abortion care for many patients. Clinicians described how the unworkability of the ban’s narrow exceptions and the severe chilling effect on abortion provision caused by the sweeping criminalization of abortion from a very early stage of pregnancy are endangering patients’ health and survival and impairing clinicians’ ability to comply with their ethical obligations and medical standards of care.

Clinicians shared multiple examples of cases of delays and denials of reproductive health care including abortion care and miscarriage management, disruption of the patient-clinician relationship, deviations from standard medical care, impaired training of new clinicians, and an exodus of health care providers from the state, worsening Florida’s already severe health care provider shortages. Alarmingly, clinicians stated that patient care is being impeded by Florida’s broad abortion ban even in cases of ectopic pregnancy, molar pregnancy, and preterm premature rupture of membranes, despite state health agency rules that state that these conditions should not be considered abortion.[5]

Clinicians interviewed described the devastating consequences of the abortion ban for their patients. Many patients do not realize they are pregnant until after the legal limit – just two weeks after a missed period – and the required 24-hour waiting period between a first face-to-face appointment with an abortion provider and receiving an abortion further narrows the window for care. Patients are referred to tertiary care centers and abortion-providing facilities within the state as hospitals grapple with confusion about what the exceptions include and direct patients to seek more specialized clinicians’ authorization to avoid risk. Ultimately, the law’s narrow exceptions do not cover many serious conditions, forcing patients to either travel out of state for medical care or continue pregnancies with severe health risks. As clinicians deliberated whether they could legally offer care, patients experiencing medical emergencies requiring pregnancy termination, miscarriages where they needed medical intervention, and even cancer faced delays and even denials of treatment due to the ban. This disruption in medical care disproportionately impacts low-income and marginalized communities, who already face barriers to prenatal and maternal health care. Additionally, the emotional and physical toll on these patients is profound, as they are often left with few possible options for care.

The broader implications of Florida’s abortion ban are alarming. Clinicians’ testimonies highlight ways that Florida’s ban is jeopardizing prenatal care and will likely further worsen the state’s already poor maternal health outcomes.[6] The ban also threatens the future of reproductive health care in Florida, as medical training in essential procedures like dilations and curettages (D&C) and dilations and evacuations (D&E) after the first trimester is severely limited. This lack of training not only impacts abortion care but also the management of miscarriages and other pregnancy complications, posing a significant risk to patient safety. Reflecting on these devastating impacts, clinicians called for the lifting of the six-week ban.

Florida’s extreme abortion ban has created an unworkable legal landscape that endangers both patients and clinicians. The ban violates individual reproductive freedom, leads to preventable suffering, and compels clinicians to deviate from established standards of care and medical ethics. These denials constitute violations of Floridians’ fundamental rights, including their human rights to life, health, privacy, freedom from torture and cruelty, and equality. This research brief underscores the urgent need to ensure the right to comprehensive reproductive health care in Florida.

Introduction

The United States (U.S.) Supreme Court ruling on June 24, 2022, in Dobbs v. Jackson Women’s Health Organization (Dobbs) overturned the 50-year-old precedent set by Roe v. Wade and eliminated the federal constitutional right to abortion.[7] Two years after Dobbs, in April 2024 the Florida Supreme Court followed suit and overturned its own 1989 judgment and decades of precedent that the Florida Constitution’s Privacy Clause protects the right to abortion.[8]  On May 1, 2024, Florida’s six-week ban took effect, shifting the legal limit for abortion from 15 weeks to six weeks from the first day of a pregnant person’s last menstrual period.[9] [10]  The six-week ban punishes any person who “willfully performs, or actively participates in, a termination of pregnancy” in violation of the law as a third-degree felony with up to five years in prison, up to a US$5000 fine, loss of medical licenses, or all the above. Unlike many other states, Florida’s ban does not clearly exempt pregnant people themselves from criminal prosecution.[11]

The six-week ban in Florida criminalizes the termination of pregnancy before many individuals are aware that they are pregnant – typically two weeks after a missed period in a standard four-week menstrual cycle. The new Florida ban provides limited exceptions in situations of medical necessity to save a pregnant person’s life; to “avert a serious risk of imminent substantial and irreversible physical impairment of a major bodily function…other than a psychological condition;” in cases of fatal fetal impairment where a pregnancy has not reached the third trimester; and in pregnancies resulting from rape, incest, or trafficking prior to 15 weeks only if the patient provides “a copy of a restraining order, police report, medical record, or other court order or documentation providing evidence” that they are obtaining the termination of pregnancy because they are a victim of rape, incest, or human trafficking.

The six-week ban replaces the previous 15-week ban that was instituted on July 1, 2022.[12] Some of the new ban’s exceptions differ from those of the 15-week ban, exacerbating confusion about when abortion is legally permitted.[13]  For example, the 15-week ban’s  “fatal fetal abnormality” exception allowed abortion “before viability,” unlike the six-week ban that states the limit is “before the third trimester.”[14]

On the same day that the Florida Supreme Court revoked state constitutional protection of abortion rights, in 2024, it also allowed a proposed amendment that would enshrine abortion rights into Florida’s Constitution to be included on the state’s November 2024 ballot for voters’ consideration.[15] The proposed Florida amendment says, in part, that no “law shall prohibit, penalize, delay, or restrict abortion before viability or when necessary to protect the patient’s health, as determined by the patient’s health care provider.” It would need approval from 60 percent of voters to be enacted.[16]

In addition, the day after the six-week ban went into effect, the Florida Agency for Health Care Administration (AHCA) released emergency rules – stating that certain pregnancy terminations, including for premature preterm rupture of membranes (PPROM), ectopic pregnancy, and trophoblastic tumors, should not be considered abortion for reporting purposes. These guidelines lack medical clarity, further confusing clinicians.[17] [18] Compounding these laws and guidelines, targeted restrictions on abortion providers (TRAP) laws (procedural requirements on facilities and individuals who can provide abortion care), along with the 24-hour waiting periods between the two required in-person abortion care appointments in Florida, further complicate service delivery and lead to confusion on how providers can best care for their patients.[19]

After the six-week ban went into effect, PHR undertook fact-finding interviews from July to August 2024 with 25 clinicians and clinicians in training to document whether and, if so, how Florida’s abortion ban is impacting patients, health care workers, and access to health care. We interviewed clinicians in obstetrics and gynecology, maternal-fetal medicine, family medicine, reproductive endocrinology, certified nurse midwifery, medical students, and genetic counselors across the state, with representation in varied practice types that include public and private hospitals, academic medical centers, private practices, and free-standing abortion-providing facilities.

In these interviews, clinicians described the serious and manifold harms the ban is causing pregnant people in the state who seek reproductive health care. The six-week ban is unclear in its guidelines and introduces barriers to care, delays in emergency reproductive services, and deviations from standard medical care. Moreover, the steep penalties, particularly when combined with other laws, create intensified fear and confusion among health care providers who do not know in what cases they legally can or cannot provide abortion care, creating strain in the patient-clinician relationship and inducing providers and trainees to leave the state. Clinicians report receiving warnings from hospital administrators, legislators, and others that they may be targeted for providing necessary abortions and that these laws are being strictly enforced. This has led to an overall chilling effect on the provision of reproductive health care and has hindered access to abortion care for pregnant people, many of whom have a medical necessity for the procedure.[20] Thus, the six-week ban has rendered the already complex legal landscape for abortion in Florida even more unworkable in practice, with restrictions that endanger both clinicians and pregnant patients in the state.

Florida’s Reproductive Health Landscape

As of 2024, 20 percent of Florida’s population – 4.6 million women- are of reproductive age (between 15 and 44 years old).[21] Health care costs and accessibility create significant barriers in access to health care generally for people of reproductive age in Florida. Florida’s health care system ranks among the worst in the U.S. in terms of accessibility and affordability, especially for women’s health, possibly driven by the lack of Medicaid expansion.[22] [23] Florida is currently experiencing extensive shortages of physicians, dentists, and mental health providers compared to the needs of the state’s population.[24] Further, an estimated 13 of Florida’s 67 counties are maternity care “deserts,” or counties without access to hospital or birth centers offering obstetric care or without obstetric care providers. Another 11 counties have low or moderate access to maternity care.

Pregnant people in Florida have long faced delays in accessing prenatal care.[25] In 2021, before the Dobbs decision, fewer than two out of every three pregnant people received prenatal care within the first four months of pregnancy (64.7 percent).[26] Florida is rated the second worst in the nation currently for the provision of prenatal care, which creates serious risks for pregnant people in the state, including already marginalized populations who face higher barriers to quality maternal health care.[27] For example, in Florida, in 2020, Black and Hispanic women died from pregnancy-related death at nearly four times and one and a half times the rate of non-Hispanic white women, respectively. [28] Of concern, nearly one in five of these pregnancy-related deaths in Florida were attributed to systemic care issues, such as a lack of standardized policies, procedures and care coordination.[29]

Over the past decades until the recent bans, abortion care was available throughout Florida. Even under the 15-week ban, Florida provided crucial access to abortion for Floridians and others in the U.S. South who lived in states with more extreme laws.[30] Prior to the Dobbs decision in June 2022, abortion was legal in Florida up to the third trimester, defined as starting 26 weeks after the last menstrual period.[31] A 24-hour waiting period for abortions went into effect in April 2022, followed shortly by the 15-week ban that went into effect in July 2022. As of March 2024, Florida had 54 abortion clinics.[32]

Once the six-week ban went into effect in May 2024, there have been significant decreases in abortions within the state in May and June compared to comparable periods last year in Florida.[33] While abortion clinics in the state continue to provide crucial care within the legal limits, many Floridians have been forced to travel outside the state for abortion care. The National Abortion Federation, which runs the largest patient assistance fund in the country to help people afford abortion care, reported a 575 percent increase in callers requesting funding in the two months since the ban went into effect in May, compared to the same time last year.[34] This has contributed to more than a 30 percent increase in wait times at abortion clinics across North Carolina, Virginia, Maryland, and Washington, DC. North Carolina has seen the largest increase despite having a 72-hour waiting period, with wait times increasing in half of the state’s 16 clinics.[35] The long-term impact on abortion clinics in Florida remains uncertain, but in other states with severe abortion restrictions 66 clinics closed across 15 states, with 14 states losing all abortion-providing facilities[36] within 100 days[37] of the Dobbs decision. Clinics in states with bans face significant challenges in maintaining[38] staff and financial viability, and even if abortion rights are restored, reversing closures can be difficult, creating lasting impacts on access to care.[39]

The passage of the six-week ban raises serious questions about the impact on Florida’s existing challenges in the provision of health care and specifically care for pregnant patients. Health care worker shortages, barriers to prenatal care, and barriers to abortion currently contribute to significant health harms in the state. Against this backdrop, it is critical to understand reproductive health care clinicians’ experiences providing care to pregnant patients under the six-week ban.

Research Methodology

In July and August 2024, the PHR research team conducted outreach to reproductive health community-based organizations and professional networks in Florida. These contacts facilitated connections to reproductive health care providers (“clinicians”), medical students and genetic counselors who have provided reproductive or pregnancy health care in Florida post-Dobbs. The research team then used snowball sampling, an established sampling strategy for research on hard-to-reach populations or sensitive topics, which has been used to conduct qualitative research in comparable studies.[40] Clinicians consented to 30- to 60-minute, semi-structured, in-depth, confidential interviews. Interview guides were developed based on the expertise of the research team and conversations with partner organizations. Transcripts were de-identified and cleaned by interviewers, and data was stored on a password-protected server and only accessed by the research teams. Study recruitment ended when we reached concept saturation, the point at which no new themes emerged from additional interviews.[41] Thematic analysis was used to identify experiences across interviews. The two interviewers (WA and MH) read transcripts of the clinician interviews after a third of the interviews were completed; through a hybrid approach they identified key themes emerging from the data (inductive analysis) and based on the research questions (deductive analysis) to develop a codebook. One interviewer (WA) coded all the transcripts, adding more codes as they emerged from the data. Illustrative quotes were selected based on key themes.[42] PHR’s Ethics Review Board (ERB) approved the study with exempt status. See Appendix 1 for characteristics of the 25 clinicians interviewed.

Findings

Florida’s abortion ban and unworkable exceptions pose insurmountable barriers to abortion care for many patients

Abortion is currently legal in Florida only until six weeks after a pregnant person’s last menstrual period (LMP) with limited exceptions.[43] As one obstetrician-gynecologist said: “While it is limited, abortion is still legal. There has definitely been some confusion. It is still legal.” While health care facilities across the state continue to provide abortion care to pregnant patients within the laws’ narrow confines, as one clinician emphasized, the unworkable exceptions and extreme gestational limits mean many patients are barred from care:

“It is virtually a total abortion ban. Most people do not know that they are pregnant at six weeks. Considering the 24-hour waiting period, it is virtually a complete ban. So, do not be fooled that this is a compromise. It is not.” (14)

Many people do not know that the timeline for calculating the abortion ban begins from the first day of the last menstrual period (LMP) on ultrasound and not the estimated date of conception

 Many clinicians noted that many of their patients did not realize that pregnancy is dated from the first day of their last menstrual period. The American College of Obstetrics and Gynecology (ACOG) measurement guidelines, for example, are based on the first day of the patient’s last menstrual period confirmed with an ultrasound measurement.[44] Clinicians reported that since the six-week ban, their patients who come in seeking an abortion right when they discover that they are pregnant are often distraught that they are considered further along in their pregnancy than they had assumed and are unable to receive an abortion within Florida. A clinician at an abortion care facility described how often she faces this:

“There is at least one person a week who is really angry and does not trust the ultrasound [results]. What is behind it is that they do not understand how the dating of pregnancy works, which is fair. It is just so confusing. And, the person is explaining to me, ‘There is no way I am six weeks pregnant. There is no way I am seven weeks pregnant, because this is when I had sex, and this is when I got pregnant.’ And I am like, ‘You are 100 percent right. I agree. That is when you got pregnant. But here is how the law and the medical world define the time of pregnancy. I am so sorry.’” (4) 

Patients who have irregular periods may have no idea what they will measure on an ultrasound once they have discovered that they are pregnant. One obstetrician-gynecologist told us: “The other day, we had a 14-week [patient] just because she does not menstruate. And she was like, ‘I have no idea. I do not know when my period was. I do not know when I conceived.’” (21)

Six weeks pass before many people realize they are pregnant or can secure an appointment with a provider to confirm results of a positive home pregnancy test

As many clinicians explained, many of their patients do not find out they are pregnant until after six weeks, at which point they no longer have the option to have an abortion in Florida except in narrow circumstances.[45] An obstetrician-gynecologist in private practice described:

“With the six-week ban, I would say it is more like the inability to really offer anything at all now. I mean, we see patients for their new obstetrician-gynecologist visits usually around eight weeks, and sometimes we see them earlier, if they are having bleeding or other issues where we end up scanning them earlier. But I do not think I have ever had a viable pregnancy that was less than six weeks that I could offer a termination. They are never less than six weeks, so it is essentially impossible. By the time we see them for their first visit, that option is already gone.” (19)

Multiple clinicians explained that because of a shortage of obstetrician-gynecologists in Florida, people are rarely able to secure a prenatal appointment to confirm the results of a pregnancy test with a dating ultrasound before six weeks of gestation. In the words of another obstetrician-gynecologist in private practice:

“The patients that I see in the office for an initial prenatal visit are almost never less than six weeks. It is incredibly rare for somebody to be able to get in less than six weeks. I would say more often it is closer to twelve. And part of that is because of the demand, we do not have enough providers to see patients, and we are a very big practice… And then patients who are coming in for something else and then discover that they are pregnant, if they are lucky enough to be less than six weeks, just have so little time to consider their options and then hopefully get in with somebody who can provide abortion if that’s what they choose.” (17)

Another obstetrician-gynecologist explained how impossible this timeline makes the option of abortion care for many of her patients:

“Most women do not know that they are pregnant that early. Also [because of] the way that we label pregnancies as six weeks of pregnancy…. they have actually only been pregnant for four weeks, and most pregnancy tests do not turn positive for those first two weeks. So, they really only have two weeks. And that is total days, not business days. They have two weeks to figure out that they are pregnant, even have that on their radar. Call and get an appointment, and then get a second appointment all within six weeks and zero days’ time, which is really hard.” (20)

Florida’s 24-hour waiting period creates an additional barrier to receiving abortion care within legal time limits

 In Florida, the first abortion appointment consists of an ultrasound to measure gestational age, where patients are read the state-mandated consent information. Patients then return at least 24 hours later for a medication (mifepristone and misoprostol) or procedural abortion (for example, D&C). Clinicians noted that clinics have been penalized by AHCA for performing abortions up to 15 weeks and six days rather than 15 weeks and zero days, under the 15-week abortion ban. While clinicians did not name a public document stating this policy, these accounts of aggressive enforcement have led facilities to err on the side of caution, and assume the same is true for the six-week ban- that to be legally eligible for abortion care under the six-week ban, the first appointment must occur no later than five weeks and six days after the beginning of a patient’s last menstrual period ifthey can schedule the abortion for the next day. However, most abortion-providing facilities are not open or do not provide abortion procedures every day of the week. As a clinician who provides abortion care described:

“[In Florida] abortion clinics are not open seven days a week. [One clinic is] open on Tuesday, Wednesday, and Thursday. So, if you are seen on Thursday and you are five weeks and four days – we cannot provide for your care. And, like, maybe a [city] an hour and a half away, is booked up, and they do not have appointments for you. And so, a six-week ban is not a six-week ban, depending on what day you are getting seen. …If you are not open for four days, it is not a six-week ban, it is a five [week] and four [day] ban.” (4)

Several obstetrician-gynecologists described how harmful the impact is on their patients who must travel to facilities hours away to receive their abortion before the six-week deadline:

“I have definitely seen patients who I do the consent, and then the next day they drive [to another city across the state] for their appointment for their abortion. …I have talked with many patients who are confused about why they are being asked to drive across the state on a day’s notice and have to drop everything they are doing, leave work, find childcare, pay for gas, and all these things. And I have to explain to them – this is not a rule that we implemented. This is based on state law, and we are just trying to help as much as we can.” (14) 

Many fetal anomalies are unable to be detected on early ultrasound imaging before six weeks

Florida’s six-week ban only permits abortion for “fatal fetal abnormalities” where termination is sought before the third trimester. The law states that “a fatal fetal anomaly” is one that is “a terminal condition that, in reasonable medical judgment, regardless of the provision of life-saving medical treatment, is incompatible with life outside the womb and will result in death upon birth or imminently thereafter.”[46]  Clinicians shared that patients faced delays and denials of abortion due to confusion about which fetal anomalies could be terminated legally, including severe anomalies that would lead to death in weeks or months – not just hours – from birth.” Clinicians described their experiences caring for patients with severe but not clearly fatal fetal anomalies during pregnancy that cannot be detected on early ultrasound imaging. One certified genetic counselor said:

“When I started practicing, the legal limit to have an abortion was 23 weeks and six days. So, for the majority of our patients at that time, we were able to get them the care. Some patients who were late to care or things were found later on ultrasounds, we helped them go out of state, but that was few and far in between. So, then when the 15-week abortion ban came into place, obviously that made things a lot harder, but we were still able to get in, not necessarily the ultrasound findings, because those are just very hard to see anything super well under 15 weeks, but the very severe ones, we would still be able to get them in. And then we really pushed for, in our practice, [getting people in] for chromosomal screening right at the 10-week mark when they can do it or as early as possible. So, when the results are back that we would be able to do diagnostic procedures at 12 weeks and then we can get those results back before the legal timing limit to get abortions. But it was hard because there was no time to spare, essentially. Like things had to get in very quickly. …But anything past that, any anomalies had to go out of state.” (22)

Fear of criminal charges has caused delays and denials of emergency reproductive health care to patients

Clinicians repeatedly shared how Florida’s narrow exceptions to the overall criminalization of abortion has led to widespread fear that has hindered access to care and harmed patients. Clinicians at tertiary care centers reported receiving increased referrals from clinicians afraid to care for complicated pregnant patients under the current laws. One obstetrician-gynecologist told us:

“I have seen a surge in patients coming to me that I was not seeing before that were being handled by the community and getting care elsewhere. Patients [are] coming desperate, [saying] ‘They would not sign off on this. I do not know what to do. They just said, go to [tertiary care hospital].’ So, I get a lot of phone calls from my residents about patients in the ER, [telling me], ‘They are 18 weeks, and they have bilateral renal agenesis [lack of both kidneys which is usually fatal] in the fetus …and they are like, ‘I want an abortion.’” (11)

One maternal-fetal medicine (MFM) specialist explained one basis for this fear: “The state has come down very hard on a couple abortion centers that [the state argued had] deviated on the cutoffs as the law changed from 15 weeks to 6 weeks. And so, the fear is that the state is actually looking for a scapegoat to go after.” (13) This MFM also noted referrals from providers afraid that they would not fill out correctly the extensive and confusing required paperwork by the state for legally allowable abortions and would thus be prosecuted:

“We are seeing tons of referrals that would not have been made before [the abortion ban]. I even see doctors that are two blocks away from me going, I am too intimidated by all the state paperwork. I know exactly that this fits the criteria, but I just do not know how to fill it out, how to date it, how to sign it. There are all these rules. We are just sending the patient to you so you can do the paperwork.” (13)               

Several clinicians described how fear and lack of clarity about the narrow medical exceptions are leading to patients being sent out of state for abortions even in situations where abortion care could be considered to be legal. One obstetrician-gynecologist hospitalist stated:

“I would say 99 percent of MFMs in our state are not entirely aware of the laws or they are scared of the laws. So instead of calling a clinician who does abortions [in Florida] and asking them, ‘Would this qualify for an exemption?’ They just automatically refer the patient out of state. Because they do not want to be on record saying that they think this is a lethal anomaly or that they think that this is going to endanger maternal life…. And so, they just say, ‘Go to North Carolina or Virginia or whatever it is. …Since the six-week [ban] went in place, literally zero clinician sign off has occurred [at my hospital], because I think people are just being directed elsewhere. [It is] just an even more unnecessary burden on the patient. Like, it is bad enough she is going through this bad outcome that she did not sign up for, now you are making her travel out of state when she really does not have to. There is a multitude of doctors in Florida who remain who are capable of doing [abortions]. But people are just scared.” (21)

Delays in securing hospital approvals due to hospital concerns about violating Florida’s abortion ban in turn are delaying emergency care for pregnant patients

Multiple clinicians recounted how the abortion ban vaguely defined narrow exceptions had led to difficulties in securing approval for medically necessary abortion care from their health care facilities. Several clinicians described cases of being required by their hospitals to wait until patients become “sick enough” to qualify for care. One obstetrician-gynecologist told us about an incident which occurred under the 15-week ban:

“I strongly remember a patient who had severe kidney disease and was admitted to the hospital and was teetering on the edge of that 15 weeks. I think she was 14 weeks or so, and she got admitted, and we were trying to figure out how best to help her. She was getting sicker and sicker…. [We] had to bring it to the head people of the hospital and be like, ‘What are we allowed to do?’ And they were like, ‘She is not sick enough yet.’ And we had to wait for her to get sicker before we were even allowed to offer her termination. And she was past 15 weeks at that point. …I think it took over two weeks for us to get an answer from the hospital administrators. …So that hit very strongly, because it was kind of insane that we had to wait for her to become sicker. We had to wait for her creatinine to bump and her kidneys to be about to fail before we were allowed to even offer her [termination]. Then we had to jump through so many hoops to be able to do it. It really changed everything that we did in our practice.” (19)

Another obstetrician-gynecologist recounted another case of delay in care for a patient facing a potentially fatal pregnancy complication:

“[There] was a patient who was like 20 to 21 weeks and developed severe Hemolysis, Elevated Liver enzymes and Low Platelets [HELLP], a life-threatening liver and blood clotting disorder of pregnancy whose definitive treatment requires removal of the fetus and placenta …She also had COVID-19 and she was very isolated and her care got significantly delayed because we had to get approval to terminate her pregnancy in the hospital and she got pretty sick.” (18)

Another obstetrician-gynecologist described the impacts on pregnant patients of long delays in securing hospital approval for medically necessary abortions:

“There were times where we had to wait weeks before we had answers. And then that is just pushing the pregnancy further and further along for a sick patient or someone who is already struggling with those choices that they were having to make.” (19)

While the six-week ban allows terminations where there is a serious risk of substantial and irreversible physical impairment of a major bodily function of the pregnant person, clinicians described delays in the provision of abortion due to confusion about what constitutes a “serious” risk as well as the need for approval by hospital administrations. One obstetrician-gynecologist shared the account of a patient with a cardiac issue who had an increased risk of death postpartum:

“After [my patient’s] fifth pregnancy, she had a spontaneous coronary artery dissection. Almost died … and she is pregnant again…. I had to present her case, and she was, I think, 18 weeks pregnant…. There is no question her life would be at risk carrying this pregnancy and it is happening again, most likely postpartum. Well, then, is the pregnancy really putting her at risk? And, you know, I had to sit before five or six or seven hospital administrators and make an argument for this woman. And the data I could pull was that there probably was up to about a 10 percent chance of this happening again, but it is a 10 percent chance of dying because if she had another spontaneous coronary dissection, she’s dead. And I had to hear these people say, ‘Well, is 10 percent a lot? Is that enough?’ I said, ‘Are you kidding me? I guarantee if you ask her five children is 10 percent a lot, a big chance of losing your mom? Does that sound like a lot? They would say yes.’ But it is this back and forth, and it is just this kind of chaos. But who makes these decisions? It just leaves you in a stalemate sometimes. … I eventually got to a point where my hospital said, okay, yes, we can do this. It took me two to three weeks to get to that point. And you obviously know [that delay] matters. You are 15 weeks, 16, 17, or 18. The procedure changes a little bit, and the risk changes a little bit.” (11)

Preterm premature rupture of membranes (PPROM) and ectopic pregnancy care is still being delayed despite AHCA emergency rule

Following the six-week ban going into effect, AHCA, a state agency, issued a rule stating procedures to treat PPROM, ectopic pregnancy, and trophoblastic tumors would not be considered abortions for state reporting purposes. Despite this, several obstetrician-gynecologists reported that their patients are afraid that they will not be able to receive care for these conditions, which makes it incredibly “challenging,” as one clinician worded it, to provide care. In the words of one: “[for] molar pregnancies, ectopic pregnancies, even though the state has said in their AHCA emergency rule that those are not, “abortion care,” there is still so much confusion and fear on the part of our patients that they are not going to be able to get care or that they will get in trouble.” (1)

Indeed, these fears are not unfounded. One obstetrician-gynecologist told us that her hospital still required them to have a two-doctor signoff for PPROM to protect them in case the state decided to prosecute, even though PPROM should not count as abortion provision under the AHCA emergency rule:

“We did get guidance after the six-week law was passed…. So now we are able to discuss with patients what we call active management if their water is broken at a PPROM. So, we are lucky compared to other states in that regard. But still, it is so intrusive. Okay, here you are. Tragic your water is broken. We are worried about these things. You do not want to stay pregnant. Let us roll in with a brochure of state paperwork. Let us start filling it all out together, because even though you know what you want, we have to do all this paperwork. And the law is not that clear. So, we still do two signatures. Like there is still a delay that occurs with all of this that seems unnecessary in a situation where delay potentially could increase the chance of infection.” (13)

Clinicians at small rural hospitals and at religious-affiliated hospitals described how their hospitals were recommending that patients with PPROM to be transferred to larger, academic hospitals or tertiary care. These delays in care could result in additional health complications for patients, and this chilling effect extends to broader pregnancy care. One obstetrician-gynecologist described a case of a patient who developed complications due to delays in referring her to another hospital for termination that the obstetrician-gynecologist would have provided before the abortion ban:

“We had a patient who had PPROM, she was like 18 weeks and she desired termination. Basically, what we have to do is send a referral to our MFM, who then can refer her to [academic hospital] for care, and in that process [the patient] got infected, got chorioamnionitis and became septic and ended up needing admission and IV antibiotics at the academic hospital. So, yeah, just not being able to just admit that patient that day and proceed with an induction was unfortunate for her.” (18)

And, as another obstetrician-gynecologist at a rural hospital recounted, options in Florida for transfers requiring abortion procedures are increasingly limited: “I have thought about that – where do I send people? So, I know if I get somebody in who wants a D&E who is PPROM, I have to send them to that one hospital because I do not think any of the other ones would do the procedure.” (5)

We also heard similar accounts about ectopic pregnancy care. One obstetrician-gynecologist told us care was still being delayed in their ER for ectopic pregnancies, as ER clinicians were afraid to provide methotrexate to patients as it was an “abortive agent”:

“I was on call and we were trying to give methotrexate and were getting pushback from one of the emergency room providers. It was mostly from nursing, but I guess the physician assistant [PA] was the one that was mediating this between us. But we had a patient who had an evacuation already and was still having rising human chorionic gonadotropin [HCGs], a hormone indicating pregnancy and to everybody in the obstetric world, that is an ectopic unless proven otherwise. And she had come in specifically to get methotrexate. Like she had been sent in from [abortion-providing facility] to get methotrexate from our team. And so, we ordered it, and we had to have this back and forth. We were EPIC chatting [texting within the medical record], having this kind of disagreement back and forth. I actually printed out the AHCA code and [a resident] brought it down and there was still a lot of back and forth. It ended up being one of our labor and delivery nurses just went down and gave the medication. It is like a very big conversation on a bunch of email threads now because of this. And we had [another] recent case, [a] similar situation where they were refusing to give it because they were concerned about the legality of giving it as an – they kept calling it an abortive agent.” (25)

Narrow and unclear exception for “fatal fetal anomalies” is causing confusion and leading to denial of care to patients with severe diagnoses

Clinicians noted that the Florida law’s exception for fatal fetal anomalies does not cover many serious conditions. The state has defined “fatal fetal abnormalities” as “a terminal condition” that is “incompatible with life outside the womb and will result in death upon birth or imminently thereafter.”[47] As one MFM specialist explained:

“So, the actual term is “imminently lethal,” which is not a medical term…. So, a patient comes in or has a condition that is genetic, and let us say 100 percent of the time, the baby is going to die of a debilitating neurologic condition by age three or by three months of age even, they cannot terminate in the state of Florida. And so, that is an interesting conversation to have with people because many people … have no idea that their rights have been stripped away. And so, I end up having conversations where people get really angry with me because they cannot terminate.” (13)

A genetic counselor told us that their hospital had decided in consultation with the lawyers that “imminently lethal” meant “lethal, essentially, within the first day of life.” (22) Another genetic counselor recounted the case of a patient whose fetal diagnosis was not considered “imminently lethal”:

“A patient had two children who had a very rare genetic condition. They passed away four months of age. …The patient came to me in her third pregnancy, had already had diagnostic testing done, and just to talk a little bit about coordinating out of state abortion. All the providers who have seen her … nobody felt comfortable saying that this is lethal immediately post-delivery. Right, because is four months immediately post-delivery? And I think it is things like that where you are sitting there and you are like, what defines, you know, severity? And this is for, you know, a mother who lost two children who did not want to go through that suffering again or see them go through that again in her words, we could not give a time limit [for lethal].” (12)

Multiple clinicians described conditions in the gray area of the law that might be quite severe, but did not meet the criteria for being lethal immediately upon delivery. These patients who do not meet this narrow criterion for exceptions are forced to travel out of state or continue the pregnancy. As one obstetrician-gynecologist said:

“There is no amount of legal wording that can account for and pay respect to the complexities of medical care that can arise. …And so, what I have seen with these families [who] are in this area of gray is that they end up needing to travel out of state for abortion care because these exceptions are very narrow. And if they happen to be unlucky enough that their baby has a condition that does not necessarily meet this narrow exception, their health care team is going to be reluctant to care for them because they do not want to be prosecuted for not following the law. And so, in many instances, I have had patients travel out of state.” (2)

Pregnant people who do not qualify for narrow exceptions must travel out of state or continue pregnancies with severe health consequences

Due to the concentration of abortion bans in the southern U.S., patients in Florida have limited options for facility-based care. The closest states with higher gestational limits are North Carolina, which currently limits abortion provision to 12 weeks with exceptions for life-limiting fetal anomalies up to 24 weeks, and Virginia, which allows abortion until viability.[48] For many patients, traveling to another state is impossible. Out-of-state travel requires that people have significant resources such as financial means, travel experience, childcare for their other children, and time off from work. A clinician at an abortion care facility said:

“There are patients who come in at six weeks, zero days to sign their consent, and 24 hours later, they would be six weeks, one day. They come in with a stroller with two babies: ‘I cannot go to North Carolina. I am a single mom. I do not have any [paid time off]. What do you want me to do here?’ And, I mean, what I am asking of them is, ‘Hey, can you travel 300 miles for a five-minute procedure or 800 miles for a five-minute procedure?’ It is insane.” (3) 

Another obstetrician-gynecologist who provided reproductive health care to incarcerated patients pointed out that they now have no options for abortion care, as the prisons will not send incarcerated pregnant people out of state for abortion care: “My patients who were in the jail, they will take them to the clinic down the street, but they are not taking them out of state.” (5)

Clinicians described patients for whom English is a second language or who have recently immigrated to the U.S. as being among those most affected, as they were often less familiar with navigating the U.S. health care system. A clinician described the difficulties of non-English-speaking patients with fetal anomalies trying to navigate the American medical system to make health care appointments in another state.

“I just had a case this past week of a very nice couple. They did not speak English. The baby had a severe, debilitating abnormality that was not lethal. … a very large spinal bifida defect. They did not have it in them to stay pregnant. And absolutely, they were going to travel out of state to get care. I went through the long discussion with the translator about everything and about the options and pulled up a couple of out of state places. And at this point, I am 45 minutes behind in my schedule… [and the patient asks,] ‘Can you call the doctors at the top three centers and tell them about me? And can you set up those appointments for me?’ And I felt so bad. I said, ‘No, actually, I cannot do that. That is something you have to do for yourself.’…. [Afterwards] it haunted me. I left her with a really daunting task.” (13)

Being forced to travel out-of-state or continue pregnancies can result in compounding harms. A genetic counselor described the emotional impacts on patients who must travel out-of-state for pregnancies with life-limiting fetal diagnoses, where people reported post-traumatic stress disorder (PTSD) and grief that was compounded by the stress of needing to leave the state to receive abortion care.

“I had some patients who … had to travel out of state for medically indicated terminations. [It] was a really traumatizing experience. [Thinking of one patient seen last week], …. to have to travel out of state and have to do everything with doctors that she did not know in a state and in a health care system she did not know. It was really hard for her. She got good care. But it is a really sad thing to have these patients you have established relationships with have to leave and be off work and hopefully have somebody with them also supporting them and spend all that money. It is just that they report PTSD and, of course, grief. But I think that the grief is a lot more complicated than it could have been.” (17)

Multiple clinicians interviewed recounted the stories of patients unable to travel out of state for care who were forced to continue their pregnancies, even if they faced precarious social, financial, or health situations. A MFM specialist recalled one recent patient:

“I had a patient who was Spanish speaking, who had a trisomy 18-week pregnancy with a heart defect. Now, 30 percent of those babies will die prior to labor, 30 percent will die in labor, and the majority that are born will die in the subsequent hours to days to weeks after birth, with a small minority able to survive beyond a year. So, we made this diagnosis at about 18 weeks gestation, but these babies can live for hours or days. And so, I knew that just sending this case for review based on state laws was unlikely to be approved because there is so much fear. So, I sent the patient to the pediatric cardiologist. They said, it is a heart defect, and the baby has trisomy 18, but I cannot say that it is a lethal heart defect. I was the one that had the relationship with the patient, so I had to crawl back to her with a translator and tell her that we could not take care of her within our hospital system. So that left her with the only option of going out of state. And that is when she started to cry. And she told me that she is the only caregiver of her mother with severe Alzheimer’s. She had two small children …it would take [two to three days] to travel out of state to get the care and to terminate. But she was like, ‘There is no one that my mother will allow in her dementia to care for her. I am stuck in this state, so I am stuck staying pregnant.’ And she did. And two months later, the baby died in utero. And you can think of all the hurt there was for her in carrying a pregnancy for eight weeks for no reason other than state laws intimidating and altering patient care.” (13)

A genetic counselor said about patients whose fetuses have severe anomalies and who continue their pregnancies because they did not meet narrow criteria for lethal fetal anomalies and could not travel:

“I am seeing patients continuing because they must. Because they do not have the finances or sometimes not even finances. A patient last week could not get childcare. She is a single mom [who] cannot travel out of state for a couple of days, even though financially, we can with some of the funds and things like that make that happen. Somebody has to take care of her kids, and she does not have that. … I feel like my job has become panic coordinator for people as opposed to, truly, we are aligning values, we are making decisions. I feel like there is this sense of panic.” (12)

Florida’s abortion ban causes deviations from standard of medical care clinicians otherwise would provide to patients, including molar pregnancies, miscarriage management, and cancer treatment

Clinicians spoke to how the ban led to violations of patient autonomy, violations of pregnant people’s freedom to make decisions about their bodies, that themselves constituted deviations from the standard of care and ethical treatment of patients:

“The standard of care is that patients have bodily autonomy, and that is one of the main ethical pillars of medicine. And when you take that away, it absolutely impacts the standard of care.” (24)

For example, another obstetrician-gynecologist told us about delays in abortion care for a patient with terminal cancer:

“She had recurrent metastatic pancreatic cancer. She beat it two times, and this was her third recurrence, and it was stage four, terminal. And because she had been on and off chemotherapy and radiation for the better part of five years, because of her recurrences, her periods had been irregular for ages…. And she has always wanted to be pregnant, but never could because of her treatments. And it was on a routine PET scan that she found out she was pregnant, unimaginable. And she was over 20 weeks, like 21 weeks. [She] had no clue because of all of the reasons I just said. Her oncologist said, ‘We have to stop treatment unless you have an abortion, essentially because this poses a risk to the pregnancy.’

She came to us for an abortion after the six-week ban at around 21 weeks pregnant, and given the oncologist saying, we have to withhold treatment, I was like, certainly that is a health exception. And it took so, so much legal back and forth to ensure that we had all this really specific documentation from her oncologist…. [And then I realized she needed hospital-based abortion care due to her medical risks which took time to find.] I ultimately found one about an hour flight away, probably about a four-hour drive away, who was willing to do it. And then we had to go through all of the legal hoop jumping for that hospital [all over again]. And then we had to tell the patient, you have to drive 4 hours for this care while you are literally dying of cancer. She ultimately got [the abortion], and, like, thank God that we were able to set it up. …

In the middle of all that, you want to grab these Supreme Court judges and bring them in the room and say, look what you are doing to people. Let this woman be able to receive palliative chemotherapy, which is the least we can do for her, for Christ’s sake. What we put her through was so cruel and unnecessary. It took over a week for her to be able to get the procedure.” (3)

Some clinicians discussed how Florida’s current abortion ban pushed them to provide abortion care earlier, when they otherwise would have strongly recommended that patients wait for more information about the pregnancy. A gestational sac is not visible at all on ultrasound until approximately 4.5 to 5 weeks of pregnancy,[49] so even in cases where a possible abnormality may be observed that early, clinicians have a limited amount of time to try to determine severity before the patients will be ineligible for abortion care.

A clinician working at an abortion care facility gave an example of this deviation from standard of care for the treatment of possible or partial molar pregnancies, which require more time to diagnose than allowed by the six-week ban[50]:

“It is happening a lot around possible molar pregnancies where it is just a weird looking ultrasound, and in an ideal world, it would be like, all right, let us get some blood work. I am not 100 percent sure this is a molar pregnancy. Let us have you come back in a week and just see what is going on. And you cannot [with a six-week ban]. It pushes you to do, like, substandard medical care.” (4)

Rather than being able to wait and confirm the molar pregnancy before deciding on treatment, clinicians need to treat patients early, before being able to confirm this on an ultrasound.[51] Additionally, clinicians noted that the law limited treatment of patients who have a medication abortion failure and needed a second round of treatment but are now past the six-week limit. Patients might then be forced to continue the pregnancy, and continuing a pregnancy after exposure to misoprostol has a small increased risk of fetal malformations.[52] A clinician at an abortion facility described the problem: 

“The other thing that worries me is if a patient who comes in and they are going to do a [medication] abortion, say, at five weeks and four days, okay, if they are one of the two percent of failure, and now they come in [for a follow-up appointment] and they are six weeks and three days, what do we tell them? Sorry, it is now illegal. That is a terrible conversation to have with somebody.” (9) 

Several clinicians described patients experiencing miscarriages being turned away from emergency departments and then facing additional barriers to care due to fear of legal risks.[53] One obstetrician-gynecologist described how Florida’s abortion ban has caused a chilling effect, where staff in the emergency department (ED) are frightened and unsure about what care they can provide under state law.

“We had a patient who must have been 13 to 14 weeks, quite small still, who came in with concern about having a miscarriage. And we had seen her down in the ED, and we could tell that she was dilated, and her water had broken…. At that time, we had not yet confirmed if there was still a heartbeat in the fetus. When I reexamined her, [she was beginning to deliver] …., and she is not bleeding out or anything, but she is crying. She and her partner are very upset. They know that this baby is not going to survive, whether it has a heartbeat or not, and that this is going to end in a miscarriage. And she is looking at me and telling me, ‘I cannot mentally handle this anymore. I know, we all know, what is going to happen. Just pull it out. I want to be done.’ And the ED nurse put her hand on my arm and was like, ‘I do not think you can do that.’ And it was just so heartbreaking to have to look at a patient and say, ‘I can see how much pain you are in right now. We know from the medical perspective that this is not a pregnancy that is going to survive into anything, and that we should just take it out. But because of everything that is happening legally right now, I do not know if I can. I need to get some more information, some more help.’” (16)

Another obstetrician-gynecologist told us about being referred cases from nearby emergency rooms (ER):

“We have gotten received a couple of [miscarriages] where an ER would not treat them for whatever reason, and the patient does not totally understand. [The ER] just kind of insisted well, just let your body take care of it. Patients are in pain, they are bleeding, they are out of work, waiting to get an appointment at [an abortion clinic], and then we have to bother them with, ‘Wait, what medical records do you have?’ Because we must legally make sure, can we clearly defend that this is a miscarriage? While the patient is standing there, frustrated and it has been a week, and they are bleeding and not working or trying to take care of their kids.” (20)

Outpatient obstetrician-gynecologists described multiple cases where a patient was clearly having a miscarriage, but care was delayed to ensure exact diagnostic criteria for miscarriage were met so that providers were protected from prosecution. One obstetrician-gynecologist told us:

“What I am seeing is just by nature of our ban and by nature of being in an outpatient setting is someone with an obvious first trimester miscarriage, but who does not quite meet diagnostic criteria for a miscarriage. Meaning, the sac must measure yay big without a yolk sac, or there must be a fetal pole that is yay big without cardiac activity. And that is how you define miscarriage strictly. But there are patients in this gray area where you come in with a big sac, and it is clearly deformed because this patient has been bleeding, but it does not yet meet those exact criteria. But the patient is bleeding and cramping and in pain and wants it out. And there is obviously a risk if this has been going on for several weeks of sepsis – it is clearly not a viable pregnancy, but it does not yet meet those exact measurement criteria…. I am always like, I could document the heck out of this, but is it enough? …I could have her come back in a couple days, show that the sac is not growing to prove that it is a miscarriage. But in that time, she is miserable, she is bleeding, she is cramping, she could, God forbid, get infected. It makes no medical sense to delay care. But legally, it is really vague. Really, really vague.” (3)

Many clinicians discussed the importance of recognizing that miscarriage treatment and abortions both may require the same medical procedures. One obstetrician-gynecologist noted that both abortion and miscarriage care are part of the full spectrum of reproductive health care that people need access to:

“Abortion care is miscarriage care. They go together and you cannot really provide one without the other. And obviously, women who have a miscarriage, that is like one of the worst times in their entire lives. And now we are making that even harder. So, women really need to have their own autonomy and be able to make decisions [in consultation with their doctors].” (18)

Clinicians described distress experienced by their pregnant patients unable to receive care, and their own distress from being unable to care for patients and uphold medical ethics

Many clinicians described the frustration, distress, and anger their patients are experiencing. One obstetrician-gynecologist said of the six-week ban, “I have had a few patients, it is very few, which is surprising to me, who are just angry at me because they need to be angry at somebody. And I just take it because I know that they are angry and I am angry, too.” (7) Another obstetrician-gynecologist said, “There is a lot of crying and there is a lot of you know, the amount of people that tell me that ‘I almost died last time [I was pregnant], what am I supposed to do now?’ is just alarming.” (21)

Clinicians discussed how hard it was to communicate to patients that they will have to travel out of state for their abortion care:

“As a doctor, you watch these patients process all of this, like, in real time, and they are all kinds of frustrated. They are confused. A couple of them ended up at some legalized harassment clinic [anti-abortion centers that try to dissuade pregnant people from having abortions] that they thought was going to provide them abortion services, and it did not and wasted their time. And they need help, and financially, they need help. Just the whole idea of transportation, a lot of them already have kids. How do they make this work? It is really urgent. And they are really vocally very frustrated.” (20)

 One clinician at an abortion-providing facility described a clinic visit after the current abortion ban with a pregnant patient from Vietnam:

“I was trying to explain to her that she was like, eight weeks or something like that. And she pleaded with me, and she started to cry, and I said, ‘I cannot do anything. It is illegal.’ And she said, ‘Just sell me the medication under the table.’ And I am like, ‘I cannot do that.’ And then she fainted in my office, and we had to revive her, and I felt really bad, and she kept [saying] ‘Please, I cannot have this baby. Please help me. Please help me.’ You know, what do you do? You just have to be as understanding and supportive as possible. But I am not going to violate the law.” (9)

Several clinicians described the reactions of pregnant patients who did not know about the abortion ban until they requested an abortion at a clinic visit with them:

“When you have to tell them that it is not available to them in their state, their frustration turns on us. Like, we had a patient [say], ‘I cannot believe that. Like, you are telling me that I cannot get [an abortion]?’ And we were like, ‘You should go out and vote in November, because, we did not make this decision, and we agree with you. You should be allowed [to have an abortion].’ So, I have definitely had the animosity of patients who maybe either knew about the laws, but it did not affect them or who did not even know that these laws were being put in place until it affected them and being really frustrated by it.” (19)

Multiple clinicians in hospitals that required them to complete the 24-hour consent paperwork with patients who were experiencing medical emergencies or fatal fetal diagnoses described how distressful this was for their patients and them. One clinician explained that her hospital required this as an extra precaution to make sure they were complying with state law and told us:

“[The state-mandated 24-hour consent] form is really painful to go through with patients… It basically says, I have been given the opportunity to view a live ultrasound image of my baby, and they have shown me specifically the heartbeat. Or like, I have been given materials and gone over materials for adoption or, you know, like, quote unquote, alternatives to proceeding through with the pregnancy. And it is a difficult conversation, especially instances where, like, the parent may not actually want to go through with having a termination of pregnancy but medically, it is in their best interest. Like, we got a transfer from an outside hospital one time for this lady who had presented to that outside hospital for a heart failure exacerbation. She was very sick from her heart failure and found out in that admission in the ED there that she was pregnant with twins at like, 16 weeks. …. She has an extremely high chance of dying just from the pregnancy. And even at this conservative, religious outside hospital that she was at, the MFM there told her that she needs to go somewhere that will help her end her pregnancy. So, they transfer her to us, of course…. And she understood. She was very much on board with, like, ‘I want to be pregnant, but I also want to be there for my five other children and my partner.’ And it is hard to just have that conversation with a patient, let alone after that conversation be like, now, here is this form where we are going to talk about all these things that are going to make you feel bad about making the right decision for yourself and your family right now.” (16)

Clinicians stated that the ban violated their overall medical ethics and that they experienced moral distress by not being able to provide the full range of reproductive health care options for patients. One clinician told us:

“Basically, what we are being asked to do with these bans is throw out everything we have learned, our judgment, our clinical decision making, patient-centered care, advocacy, equitable health care, autonomy, and beneficence. We are basically being asked to throw every tenet of medicine out the window, and for me, abortion care is health care. It is the highest level of compassion and care and love that you can give to someone. …I am being told I cannot be a doctor, and if I want to be a doctor, I will go to prison for five years. It just puts patients in horrible situations that you would not wish upon your worst enemy. And that you definitely would never, ever want to go through yourself or have someone that you loved or cared about go through.” (11)

Another obstetrician-gynecologist said:

“I can provide [abortion care] up to essentially 24 weeks. I have the skills to do that. It feels, again, dumb. Like, so stupid that I have to go into six weeks, one day patient and be like, yeah, I cannot do anything. We have to help you get out of state…. Especially when, you know, there is no medical reason for it. There is no other field of medicine where people are like, oh, sorry, I cannot do your colonoscopy or whatever, because I just cannot. And that is tough on all [the doctors at her facility]. I think everyone has the skills. We cannot use them. We have the knowledge; we know it is safe. And so, you are turning people away for no real reason except to avoid going to jail, which is crazy.” (23)

An obstetrician-gynecologist described succinctly the conflicts she and other reproductive health care providers face between adhering both with Florida’s laws and her medical ethical obligations to her patients:

“I tend to err on the side of, if I do not comply with the law, then I cannot help the next patient that needs this help. But it is a hard situation to be in just trying to do what is legal but also do what is right. It is not always the same thing.” (24)

Florida’s abortion ban is exacerbating maternal health and mortality due to impacts on training new clinicians and trained clinicians leaving the state

Clinicians involved with medical student and resident training described how the inability to provide training in abortion care is detrimental to the future of maternal health care in the state. Several obstetrician-gynecologists told us stories about how the lack of comprehensive abortion training impacts the provision of broader reproductive health care and noted that this problem pre-dates the Dobbs decision. One obstetrician-gynecologist explained that the lack of providers trained in D&E procedures was already a problem in Florida before the abortion ban and that this shortage would likely worsen if current residents did not receive training in Florida:

“I have graduated a large number of residents who end up staying somewhere in the area and they all inevitably end up calling me, [saying] ‘I have this stillbirth at 20 weeks. She has a previa and three sections. She is really not a candidate for an induction.’ And they are going to section her. What, you are going to cut this woman open at 20 weeks? Like literally you are going to just split her uterus in half for no good reason. But this is what is being done to everybody across the state because nobody knows how to remove a fetus through the vagina anymore.” (21)

This is a problem as D&E procedures are important to broader obstetrics and gynecology practice. As one clinician stated: “Even if you decide you are never going to provide abortion care, you are going to be in a situation where you are going to need to evacuate a pregnant uterus at 14 to 16 weeks. And it is essential that you know this.” (7)

Clinicians further noted that trainees and established reproductive health care providers are choosing to leave the state and thus are further exacerbating existing shortages of providers. In the words of one obstetrician-gynecologist: “We are seeing providers leave. We are seeing residents not apply to the state of Florida because they want that training.” (10) Another obstetrician-gynecologist told us:

“We are going to lose doctors. There is zero question. And what is interesting as well, you know, the state might say, ‘Well, good riddance of abortion providers like, we do not want you, we do not need you.’ But I am talking about general obstetrician-gynecologists, MFMs who are like, I cannot provide the care and the counseling I need to understand these laws. I am going to leave. And we already have a shortage of obstetrician-gynecologists in Florida.” (11)

 Several clinicians emphasized the adverse effects of the abortion ban on training for miscarriage management. As an obstetrician-gynecologist explained:

“One in three women in their lifetime will have a miscarriage. One of three pregnancies end in miscarriage. And so many people can be affected by this because the medical term for miscarriage is spontaneous abortion. And people writing these laws are not looking at the medical terminology, the medical understanding. At the end of the day, if we are not training our clinicians to be able to care for patients, for the one in three pregnancies needing this kind of care, hopefully not all of them need surgical intervention. But if we are not able to train our providers to safely provide this care, we are doing a huge disservice to the state of Florida.” (10)

Additionally, obstetrician-gynecologists described the negative impacts the abortion ban will have on maternal health and mortality overall in Florida, a state that already had poor maternal health outcomes.

“You, the bearer of the uterus, are 14 times more likely to die from being pregnant and delivering full term than from having an abortion. 14 times more likely to die. Forget hemorrhage, psychiatric dysfunction, infections, lacerations. I am not talking about morbidity. I am talking about mortality. And that is based on a study of a maternal mortality ratio of 8.8 to 100,000. Florida is in the low twenties. And that is even worse for people of color. So, we are actively condemning people to death by instituting these bans. And I feel like nobody understands this. Why are we trying to make our mothers die? That makes no sense. And I promise you that both Republican and Democratic mothers will die because this is not a partisan issue. This is medicine. …You need to be on alarm about the kind of training your doctor is getting because there are simply no doctors who can do this anymore. And the entire public should be alarmed because when a bad and weird and an unexpected thing happens in your pregnancy, your doctor will not know how to help you. And that is alarming.” (21)

Florida’s abortion ban interferes with individual freedom to access health care

When asked what they wished people knew about Florida’s abortion ban, many clinicians emphasized that the abortion ban interferes with individual freedom to access reproductive health care. International human rights law recognized that legal restrictions on abortion can violate numerous human rights, including the rights to life, health, equality, freedom from torture and cruelty, and reproductive autonomy.[54] The World Health Organization has found that the criminalization and penalization of abortion care – even with an exception for medical necessity – is fundamentally inconsistent with evidence-based, ethical, and patient-centered health care.[55] In the words of one Florida obstetrician-gynecologist: “It is really interfering in something that should never get interfered with, which is somebody’s private health care.” Another obstetrician-gynecologist said:

“I think I would like the public to see that abortion care is part of pregnancy care and basic health care. And when it comes to basic health care decisions, Floridians and Americans deserve the right to make these private medical decisions based on science within the context and support of their health care team and without politicians telling them what to do. That is the key thing. I would almost argue that it is not about abortion. You can choose to have an abortion, you can choose to continue the pregnancy and parent, you can choose to continue the pregnancy and make an adoption plan. It is about privacy and choice for your family and your body. Abortion is a part of that, but it is about the fundamental right to choice and privacy.” (2)

Several physicians emphasized the importance of recognizing the manifold physical harms of this governmental interference in private medical decisions between pregnant patients and their physicians. In the words of one obstetrician-gynecologist:

“Being able to provide this type of care without the fear of not only affecting your patient,     but your institution, your own license, it goes a very long way. And that this care that we are providing is lifesaving. I just feel like people have such a limited perception of what abortion care is and having seen the scary side of people being denied it, it is scary. And I am thankful that some people do not have to know the reality of that, but I sometimes wish that they did know the reality of the implications of limiting this.” (25)

Another obstetrician-gynecologist discussed how the bans on abortion also impact other reproductive health care, like in-vitro fertilization (IVF) and contraception:

“There is fear in the IVF community that fertility treatments will be the next to be banned because at the end of the day, whether it is abortion, fertility treatments, or contraception, it is all about bodily autonomy. Do women have autonomy over their own bodies? Who has control? It is clearly not about supporting families and children, because if you wanted families, then you would let IVF happen because that is creating more lives.” (10)

Multiple clinicians also discussed that they wanted people to know that abortion care is safe and should not be restricted through criminal bans. One obstetrician-gynecologist told us:

“Abortion is really safe, and there is this strange misconception that it is dangerous, but the risks of an abortion are lower than the risks of pregnancy at baseline. It is medical care, and we should not be restricting any type of medical procedure.” (17)

Conclusion

The findings of this research brief illustrate the urgent need to reverse Florida’s abortion ban and restore decision-making on individual health care to patients in consultation with their health care providers. The health care providers interviewed by PHR described multiple adverse effects of Florida’s abortion ban on pregnant people’s health, well-being, and human rights. They reported delays and denials of reproductive health care including in medical emergencies, deviations from standard medical care, disruption of the patient-clinician relationship, the need for patients to seek care outside of Florida, negative impacts on training new clinicians and retention of health care providers in the state, and adverse effects on individual freedom and bodily autonomy. Social determinants of health and racial and ethnic disparities significantly exacerbate these issues for many women in the state of Florida.

Florida’s current abortion ban has broadly impaired physicians’ ability to provide the proper standard of health care. Even the narrow exceptions to the ban have proven unworkable in practice, due to the confusion caused by non-medical terminology in the laws and fear arising from the significant penalties for violations of the ban. While physicians do continue to provide care where allowable under state law, the current abortion ban affords patients only a very narrow time frame to identify the pregnancy and access abortion care before five weeks and five days after the first day of a patient’s last menstrual period, the last day to make the first abortion appointment to be seen at six weeks with Florida’s 24-hour waiting period. Patients who receive severe fetal diagnoses later in pregnancy that are not deemed “imminently lethal” upon delivery are not able to receive abortion care in Florida and are being forced to leave the state for that care.

Furthermore, the fear of punishment for violating Florida’s abortion law by providing care to patients who are not experiencing an immediate risk of death has led clinicians to feel unable to provide treatment until patients develop additional health complications. Multiple clinicians at rural or religiously affiliated hospitals discussed having to refer patients to tertiary care centers for medical emergencies, due to hospital concerns about providing abortion care under Florida’s current laws. This included referring cases of miscarriage management and patients with conditions that were deemed exempt from Florida’s abortion ban.

These accounts demonstrate the extreme chilling effect caused by Florida’s unclear, punitive, and sweeping abortion ban on the provision of reproductive health care. Clinicians stated that Florida’s unworkable medical exceptions are leading to widespread fear and confusion that significantly threatens Floridians’ ability to access even routine medical care and jeopardizes their health and well-being. Clinicians stated that the abortion ban limits an individual’s reproductive freedom to make decisions about their reproductive health care. They reported feeling anguish that their inability to provide their patients with options for the full spectrum of standard medical care constituted a violation of their medical ethics and professional obligations to their patients. Many clinicians told us that they were considering leaving Florida and mentioned their colleagues who had already left the state due to this governmental infringement on their practice of medicine. They also expressed concerns about the impacts of the ban on training for residents and medical students, who need sufficient training in D&C and D&E procedures not just for abortion provision, but also for miscarriage management and emergency care later in pregnancy.

These concerns highlight that the state’s abortion ban has adverse consequences not just for the current landscape of abortion access but also for health care more broadly in Florida. It is essential to remedy the insurmountable barriers to care and devastating harm to Floridians caused by the state’s extreme abortion restrictions. Health care providers must be able to again meet their professional obligations to provide comprehensive reproductive health care for their patients, including termination of pregnancy.

Acknowledgements

This research brief was researched and written by Physicians for Human Rights (PHR) Consultant Whitney Arey, PhD; PHR staff members Michele Heisler, MD, MPA, medical director; and Payal Shah, JD, director of research, legal, and advocacy; and PHR intern Danielle Whisnant.

The brief was reviewed and edited by PHR staff members Saman Zia-Zarifi, JD, LLM, executive director; Karen Naimer, JD, LLM, MA, director of programs; Wacera Wathigo, MA, publications and communications manager; and by Elizabeth Singer, MD, MPH, PHR medical expert. Karla Torres, Elisabeth Smith, and Caroline Sacerdote also provided invaluable external reviews.

PHR is grateful to all the Florida clinicians who shared their time and experiences with our research team and to Dr Samantha Baer for assisting with recruitment.

Glossary of Terms

Cesarean birth: The birth of a fetus from the uterus through an incision (cut) made in the pregnant person’s abdomen.

Chorioamnionitis or intraamniotic infection: An acute inflammation of the membranes the placenta, typically due to bacterial infection after rupture of the membranes.

Dilation and Curettage (D&C): A procedure in which the cervix is opened (dilated) and a thin instrument is inserted into the uterus to remove tissue from inside the uterus (curettage). It is used for both diagnostic and therapeutic purposes, including for first-trimester abortion or after a miscarriage to remove all pregnancy tissue.

Dilation and Evacuation (D&E): The most common method of abortion after about 14 weeks pregnancy in which the cervix is opened (dilated) and the contents of the uterus are removed (evacuated) using instruments and a suction device. It is also a common procedure used after a miscarriage to remove all pregnancy tissue.

Ectopic pregnancy: A pregnancy in a place other than the uterus, usually in a fallopian tube.

Family Medicine: A medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body, including obstetric care.

Vacuum aspiration: The removal of the contents of the uterus using a suction device.

Maternal-Fetal Medicine (MFM) specialist: Also known as a perinatologist, an obstetrician-gynecologist with additional training in caring for pregnant patients with high-risk pregnancies.

Medical management of miscarriage: There are three main treatments for early pregnancy loss aimed at removing any pregnancy tissue left in the uterus: expectant management (letting the tissue pass on its own); medication; or a procedure (dilation and curettage).

Medication abortion: The use of medications to induce abortion. The World Health Organization endorses two regimens: one is the combination of mifepristone and misoprostol and the other uses misoprostol alone.

Obstetrics-gynecology (ob-gyn): The medical specialty that encompasses the two subspecialties of obstetrics (care of pregnant patients) and gynecology which focus on reproductive health and pregnancy. These clinicians are often called “ob-gyns” and the specialty of obstetrics is often called “OB.”

Preterm premature rupture of membranes (PPROM): A condition where the pregnant person’s amniotic sac (bag of water) breaks prior to 37 weeks’ gestation and prior to the onset of labor. Delivery occurs within one week of PPROM in 50 percent of patients.

Qualitative research: A type of research that gathers and analyzes nonnumerical data in order to gain an understanding of individuals’ social reality, including understanding their perceptions of their experiences, attitudes, beliefs, and motivations.

Self-managed abortion: Where a pregnant person performs their own abortion outside the formal health care system.

Spontaneous abortion: Also called a miscarriage, it is the loss of a pregnancy before 20 weeks’ gestation.

Standard of care: Treatment that is accepted by medical experts as the most appropriate for a certain type of disease in a particular setting and is widely used by health care professionals. Also called best practice, standard medical care, best available therapy, and standard therapy.

References

---

[1] Dobbs v. Jackson Women’s Health Organization. No. 19-1392, 597 U.S. (2022), https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf

[2] Fla. Stat. § 390.0111(1)(d). Access: http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0390/Sections/0390.0111.html

[3] Planned Parenthood of Southwest and Central Florida, et al. v. State of Florida et al. No. SC2022-1050 (2022), https://supremecourt.flcourts.gov/content/download/2285280/opinion/Opinion_SC2022-1050

[4]  Fla. Stat. § 390.0111(1)(d). Accessed September 9, 2024.    http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0390/Sections/0390.0111.html

[5] “Florida Administrative Code and Florida Administrative Register,” Florida Department of State, May 2, 2024, https://www.flrules.org/bigdoc/view_section.asp?Issue=4132&Section=4

[6] “Maternal Deaths in Florida: Report by Month,” FL Health Charts, 2022, https://www.flhealthcharts.gov/ChartsDashboards/rdPage.aspx?rdReport=InfantDeath.DataViewer&cid=0392

[7] Dobbs v. Jackson Women’s Health Organization. No. 19-1392, 597 U.S., https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf

[8] Planned Parenthood of Southwest and Central Florida, et al. v. State of Florida et al. No. SC2022-1050, (2022) https://supremecourt.flcourts.gov/content/download/2285280/opinion/Opinion_SC2022-1050

[9] “Why is a 6-week abortion ban nearly a total ban? It’s about how we date a pregnancy,”NPR, May 1, 2024. https://www.npr.org/sections/health-shots/2024/05/01/1248416546/6-week-abortion-ban-explainer-pregnancy-lmp

[10] Fla. Stat. § 390.0111(1)(d). Accessed September 9, 2024. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0390/Sections/0390.0111.html

[11] Florida Senate. Bill 300, An Act Relating to Abortion. 2023. https://www.flsenate.gov/Session/Bill/2023/300/BillText/er/PDF

[12] “Florida Abortion Ban Upheld by State Supreme Court,” AP News, May 1, 2024.  https://apnews.com/article/florida-abortion-ban-supreme-court-ruling-6a4949fc7459afe9b5e298086a793126

[13] “Florida Gov. Ron DeSantis signs a bill banning abortions after 15 weeks,” NPR, April 14, 2022, https://www.npr.org/2022/04/14/1084485963/florida-abortion-law-15-weeks

[14] http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0390/0390.html

[15] “Florida’s 6-week abortion ban is now in effect, curbing access across the South,” NPR, May 1, 2024, https://www.npr.org/2024/05/01/1247990353/florida-6-week-abortion-ban-south

[16] “Florida Amendment 4, Right to Abortion Initiative (2024),” Ballotpedia, Accessed September 9, 2024. https://ballotpedia.org/Florida_Amendment_4,_Right_to_Abortion_Initiative_(2024)

[17] “Florida clarified abortion rules after enacting ban. Doctors say it’s ‘gaslighting’ and unhelpful,” Salon, May 8, 2024. https://www.salon.com/2024/05/08/florida-clarified-abortion-rules-after-enacting-ban-doctors-say-its-gaslighting-and-unhelpful/

[18] “Florida Administrative Code and Florida Administrative Register,” Florida Department of State, May 2, 2024, https://www.flrules.org/bigdoc/view_section.asp?Issue=4132&Section=4

[19] “TRAP Laws: A Threat to Abortion Rights You Don’t Know About,” ACLU of Florida, Accessed September 9, 2024. https://www.aclufl.org/en/news/trap-laws-are-threat-abortion-rights-you-dont-know-about

[20] “Number of Florida Abortions Are Down After the 6-Week Limit Goes into Effect,” Health News Florida, published August 12, 2024, https://health.wusf.usf.edu/health-news-florida/2024-08-13/number-of-florida-abortions-are-down-after-the-6-week-limit-goes-into-effect

[21] “Interactive Map: US Abortion Policies and Access After Roe,” Guttmacher, policies current as of September 5, 2024, https://states.guttmacher.org/policies/florida/demographic-info

[22] Radley, David C., Jesse C. Baumgartner, and Sara R. Collins. “2022 Scorecard on State Health System Performance: How Did States Do During the COVID-19 Pandemic?” Commonwealth Fund, June 2022, https://doi.org/10.26099/3127-xy78;

Radley, David C., Jesse C. Baumgartner, and Sara R. Collins. “The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive Care Shrinks, But States Have Options.” Commonwealth Fund, June 2023. https://doi.org/10.26099/fcas-cd24;

[23] “Interactive Map: US Abortion Policies and Access After Roe,” Guttmacher, policies current as of September 5, 2024,

https://states.guttmacher.org/policies/florida/demographic-info

[24]“Addressing Florida’s Escalating Physician Shortage: Strategies and Solutions,” Florida Tax Watch, published January 10, 2024, https://floridataxwatch.org/Research/Full-Library/addressing-floridas-escalating-physician-shortage-strategies-and-solutions

[25] March of Dimes. Perinatal Data Center State Summaries: Florida. 2022. https://www.marchofdimes.org/peristats/state-summaries/florida?lev=1&obj=3&reg=99&slev=4&sreg=12&stop=55&top=3

[26] “Adequate Prenatal Care in United States,” America’s Health Rankings, United Health Foundation, accessed September 9, 2024. https://www.americashealthrankings.org/explore/measures/prenatalcare_adquate

[27] “Adequate Prenatal Care in United States,” America’s Health Rankings, United Health Foundation, accessed September 9, 2024. https://www.americashealthrankings.org/explore/measures/prenatalcare_adquate

[28] “Pregnancy-Associated Mortality Review Update, 2020,” Florida Department of Health, Accessed September 9, 2024, https://www.floridahealth.gov/statistics-and-data/PAMR/FLMMRC-2020-update.pdf

[29] Pregnancy-Associated Mortality Review Update, 2020,” Florida Department of Health, Accessed September 9, 2024, https://www.floridahealth.gov/statistics-and-data/PAMR/FLMMRC-2020-update.pdf

[30] “Monthly Abortion Provision Study,” Guttmacher, Accessed September 9, 2024, https://www.guttmacher.org/monthly-abortion-provision-study

[31] Florida Senate. Bill 5, An Act Relating to Reproductive Health and Pregnancy. 2022.   https://www.flsenate.gov/Session/Bill/2022/5/BillText/er/PDF (showing how 2022 SB 5 modified the prior ban).

[32] “The Number of Brick-and-Mortar Abortion Clinics Drops, as US Abortion Rate Rises: New Data Underscore the Need for Policies that Support Providers,” Guttmacher Institute, June 2024, https://www.guttmacher.org/report/abortion-clinics-united-states-2020-2024

[33] “Number Of Florida Abortions Are Down After The 6-Week Limit Goes Into Effect”, Health News Florida, August 12, 2024. https://health.wusf.usf.edu/health-news-florida/2024-08-13/number-of-florida-abortions-are-down-after-the-6-week-limit-goes-into-effect

[34] “The Fallout Of Florida’s Abortion Ban Has Been ‘Chaos,’ Experts Say,” Salon, August 8, 2024, https://www.salon.com/2024/08/08/the-fallout-of-floridas-abortion-ban-has-been-chaos-experts-say/

[35] “How Florida’s Abortion Law Is Affecting East Coast Abortion Clinics,” Washington Post, published May 24, 2024, https://www.washingtonpost.com/nation/2024/05/24/abortion-clinics-wait-time-florida-law/

[36] “Clear and Growing Evidence That Dobbs Is Harming Reproductive Health and Freedom,” Guttmacher, May 2024,

https://www.guttmacher.org/2024/05/clear-and-growing-evidence-dobbs-harming-reproductive-health-and-freedom

[37] Quotes have been edited for clarity and conciseness. 

[38]  “Why Providers Say Abortion Ban Exceptions Continue to Cause Confusion,” NPR, published June 14, 2024, Access: https://www.npr.org/2024/06/06/nx-s1-4995739/abortion-exceptions-life-mother-florida#:~:text=That%20law%20includes%20an%20exception,could%20face%20felony%20criminal%20charges; Supreme Court of Florida, Planned Parenthood of Southwest and Central Florida, et al. v. State of Florida et al. Available at: https://supremecourt.flcourts.gov/content/download/2285280/opinion/Opinion_SC2022-1050

[39] “Post-Dobbs, abortion clinics find new ways to serve patients in states with bans,” CNN, published June 19, 2024,

 https://www.cnn.com/2024/06/19/health/abortion-clinics-in-banned-states-pivot/index.html; Hawkins SS, Ghiani M, Harper S, Baum CF, Kaufman JS. Impact of State-Level Changes on Maternal Mortality: A Population-Based, Quasi-Experimental Study. American Journal of Preventive Medicine. 2020;58(2):165-174. doi: 10.1016/j.amepre.2019.09.012

[40] Whitney Arey et al., Abortion Access and Medically Complex Pregnancies Before and After Texas Senate Bill 8, 141 Obstetrics & Gynecology 995 (2023); Whitney Arey et al., A Preview of the Dangerous Future of Abortion Bans – Texas Senate Bill 8, New England J. of Med. (Aug. 4, 2022), https://www.nejm.org/doi/full/10.1056/NEJMp2207423;

Carolyn Payne & Angela Frankel, Changes in Young Pro-Choice Physicians’ Attitudes Towards Abortion Provision in Residency and Early Practice [05J], 135 Obstetrics & Gynecology 104s (2020), DOI:10.1097/01.AOG.0000664264.55609.56 https://journals.lww.com/greenjournal/abstract/2020/05001/changes_in_young_pro_choice_physicians__attitudes.362.aspx;

J.A. Reeves et al., Anesthesia providers’ perspectives on abortion provision: deductive findings from a qualitative study, 49 Int’l J. of Obstetric Anesthesia 103239 (2021), https://doi.org/10.1016/j.ijoa.2021.103239;

Catherine Marshall & Gretchen B. Rossman, Designing Qualitative Research (6th ed. 2015).

[41] John W. Creswell, Research Design: Qualitative, Quantitative, and Mixed Methods Approaches (2nd ed. 2022).

[42] Quotes have been edited for clarity and conciseness.

[43] “Why Providers Say Abortion Ban Exceptions Continue to Cause Confusion,” NPR, published June 14, 2024, https://www.npr.org/2024/06/06/nx-s1-4995739/abortion-exceptions-life-mother-florida#:~:text=That%20law%20includes%20an%20exception,could%20face%20felony%20criminal%20charges;

Supreme Court of Florida, Planned Parenthood of Southwest and Central Florida, et al. v. State of Florida et al. Available at: https://supremecourt.flcourts.gov/content/download/2285280/opinion/Opinion_SC2022-1050

[44] “Methods for Estimating the Due Date,” American College of Obstetricians and Gynecologists (ACOG), May 2017, https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/05/methods-for-estimating-the-due-date

[45] “The Frequency of Pregnancy Recognition Across The Gestational Spectrum and Its Consequences in The United States,” National Library of Medicine, published May 16, 2022; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9321827/

[46] Fla. Stat. § 390.011(6).

[47] ROA  15-16 (citing HB  5, §§ 3(6), 4 (codified at §§ 390.011(6), 390.0111(1)(a)-(c), Fla. Stat.)).  http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0390/0390.html

[48] “Florida Abortion Ban Prompts Two Southern States to Prep for an Influx of Patients,” NBC News, April 4, 2024, https://www.nbcnews.com/health/womens-health/florida-abortion-ban-other-states-prepare-influx-rcna146130

[49] Richardson A, Gallos I, Dobson S, Campbell BK, Coomarasamy A, Raine-Fenning N. Accuracy of First-Trimester Ultrasound in Diagnosis of Intrauterine Pregnancy Prior to Visualization of The Yolk Sac: A Systematic Review and Meta-Analysis. Ultrasound Obstet Gynecology, 2015 August; 46(2):142-9.

[50] “Epidemiology, Diagnosis, and Treatment of Gestational Trophoblastic Disease: A Society of Gynecologic Oncology Evidenced-Based Review And Recommendation,” Gynecologic Oncology, December 2021, https://www.gynecologiconcology-online.net/article/S0090-8258(21)01421-9/fulltext; Zhang RQ, Zhang JR, Li SD. Termination of a Partial Hydatidiform Mole and Coexisting Fetus: A Case Report. World J Clin Cases. 2019 Oct 26;7(20):3289-3295. doi: 10.12998/wjcc. v7.i20.3289. PMID: 31667181; PMCID: PMC6819279.

[51] Soper, John T. MD. Gestational Trophoblastic Disease: Current Evaluation and Management. Obstetrics & Gynecology 137(2): p 355-370, February 2021. | DOI: 10.1097/AOG.0000000000004240

[52] “Risk of Fetal Malformations,”Clinical Updates in Reproductive Health, last reviewed: September 23, 2022,https://www.ipas.org/clinical-update/english/recommendations-for-abortion-before-13-weeks-gestation/medical-abortion/risk-of-fetal-malformations/; Grossman, Daniel et al. “Continuing Pregnancy After Mifepristone and ‘Reversal’ of First-Trimester Medical Abortion: A Systematic Review.” Contraception 92 (2015): 206–211

[53] “Dozens of Pregnant Women, Some Bleeding or In Labor, Being Turned Away from ERs Despite Federal Law,”

Associated Press, updated August 14, 2024, https://www.wusf.org/health-news-florida/2024-08-12/dozens-pregnant-women-bleeding-in-labor-turned-away-er-despite-federal-law-florida-abortion-bans

[54] “Office of the United Nations High Commissioner for Human Rights (OHCHR)”, Abortion: Information Series on Sexual and Reproductive Health and Rights (Geneva: OHCHR, 2020),  https://www.ohchr.org/sites/default/files/INFO_Abortion_WEB.pdf; See Commission on Economic, Social and Cultural. Rights, General Comment No. 22: On the right to sexual and reproductive health (Article 12 of the International Covenant on Economic, Social and Cultural Rights) UN Doc. E/C, 12/GC/22 (May 2, 2016); e UN Human Rights Commission, General Comment No. 36: On Article 6 of the International Covenant on Civil and Political Rights, on the right to life, UN Doc. CCPR/C/GC/36, at 8 (September 3, 2019), https://www.ohchr.org/sites/default/files/Documents/HRBodies/CCPR/_CCPR_C_GC_36.pdf ; Human Rights Commission, Siobhán Whelan v Ireland: Views Adopted by the Committee Under Article 5 (4) of the Optional Protocol, Concerning Communication No. 2425/2014, 7.5–7.7, 7.9, 7.11–7.12, U.N. Doc. CCPR/C/119/D/2425/2014 (2017); Human Rights Commission, Amanda Jane Mellet v Ireland: Views Adopted by the Committee under Article 5 (4) of the Optional Protocol, Concerning Communication No. 2324/2013, 7.4–7.6, 7.8, 7.10–7.11, UN Doc. CCPR/C/116/D/2324/2013 (2016); Brief for UN Mandate Holders as Amici Curiae Supporting Respondents, Dobbs v. Jackson Women’s Health Organization, No. 19-1392 (U.S. September 20, 2021), at 31-32.

[55] World Health Organization (WHO), Abortion Care Guideline, pp13-14 (2022), https://www.who.int/publications/i/item/9789240039483; CRR, WHO’s New Abortion Guideline: Highlights of Its Law and Policy Recommendations (March 2022), https://reproductiverights.org/wp-content/uploads/2022/03/CRR-Fact-sheet-on-WHO Guidelines.pdf.