A wave of newly approved abortion restrictions in the Southeastern United States has sent providers scrambling to reconfigure their services for a region with already severely limited access.
South Carolina joined the Southern states putting stiff restrictions on the procedure Thursday when the governor signed a bill banning most abortions around six weeks of pregnancy, setting up an anticipated legal challenge from providers. The law goes into effect immediately.
"This is a great day for life in South Carolina, but the fight is not over. We stand ready to defend this legislation against any challenges and are confident we will succeed," Republican South Carolina Gov. Henry McMaster said in a statement.
Pending bans at varying stages of pregnancy in North Carolina and Florida - states that had been holdouts providing wider access to the procedure - are threatening to further delay abortions as appointments pile up and doctors work to understand the new limitations.
"There's really going to be no way for the whole abortion-providing ecosystem to manage it all," said Jenny Black, the president of Planned Parenthood South Atlantic.
Black, who oversees the organization's work in North Carolina, South Carolina, West Virginia and parts of Virginia, said providers have had to quickly determine how to comply with the pending laws amid the "decimation of abortion access across the South." She expects new restrictions will compound the stressors on a system that was already seeing lengthy waiting periods in North Carolina driven by an influx of patients from Georgia and Tennessee.
Abortion is severely restricted in much of the South, including bans throughout pregnancy in Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Oklahoma, Tennessee, Texas and West Virginia. In Georgia, it's allowed only in the first six weeks.
A report released in early April by the Society of Family Planning found rising numbers of abortions in states near those with the deepest restrictions but where abortion had remained largely legal. Florida and North Carolina were among the states with the biggest increases - and among those where new restrictions are pending.
Most abortions after 12 weeks of pregnancy will be banned in North Carolina beginning July 1 and a six-week ban in Florida will take effect only if the state's current 15-week ban is upheld by the state Supreme Court.
South Carolina had also proven to be a key destination for people seeking abortions. Provisional state Health Department data showed larger numbers of out-of-state patients after the state's highest court overturned previous restrictions and left abortion legal through 22 weeks.
The new law signed by South Carolina governor's will change that status, according to Caitlin Myers, an economics professor at Middlebury College. Myers, who studies the effects of reproductive policies, said limited evidence suggests about half of the people who want abortions won't be able to make the six-week threshold.
"It's likely to end up sending a lot of desperate people seeking abortions even farther distances and result in even greater congestion at the facilities that are left to receive them," Myers said.
The action comes as many state legislatures convene for their first regular sessions since the U.S. Supreme Court struck federal abortion protections. Over the past two months, Republican officials in North Carolina, South Carolina and Florida have pushed Virginia closer to being a regional outlier as a place with relatively permissive access.
The tide of state-level activity has been welcomed by anti-abortion groups who had long chipped away at access. Caitlin Connors, the southern regional director for Susan B. Anthony Pro-Life America, celebrated the recent legislative changes as victories made possible by last summer's ruling.
"We are officially in an era where states who have tried to pass pro-life legislation - laws that would protect unborn children, laws that would also implement services for moms and families and babies - to finally be able to be enacted and not be under the chokehold of the Roe v. Wade decision," Connors said.
That shifting landscape has also heightened uncertainty among providers that has kept them from expanding services, Myers said, and likely will prevent some patients from getting abortions as doctors weigh what is and isn't permissible.
Erica Pettigrew, a family medicine doctor in North Carolina, said the new restrictions will make it much more difficult for her to help patients navigate the system. Although North Carolina Republicans pitched the new 12-week limit as a middle-ground change, Pettigrew pointed to other provisions that make it much more restrictive.
New hurdles require that women make in-person visits to a medical professional at least 72 hours before the procedure. The three-day waiting period could previously be initiated over the phone. The law also requires a doctor to schedule a follow-up visit for women who have a medically induced abortion, increasing the hardship on those who travel from other states.
Those regulations will make it harder to advise patients on their options, she said, especially when waiting periods already spanned two to four weeks in some cases.
Other delays may result from what Pettigrew called unclear exceptions for certain life-threatening conditions.
"Now we're in this horrible purgatory of trying to figure out how to interpret it, how we can comply with the law," Pettigrew said. "There's so many unknowns."
What is in the South Carolina ban?
Women will be required to have to in-person doctors appointments before they can receive an abortion.
Under the ban, pregnant women cannot be criminally prosecuted or face civil liability for violations of the ban.
If the fetus is alive in utero, physicians are required to make reasonable efforts to preserve the life of the unborn child, provided that does not pose a risk to the health of the pregnant women, according to the bill. Entities that violate this will be fined up to $50,000, according to the bill.
Physicians who perform abortions under the health exceptions have to rationalize why they believe the woman qualifies for the exception in her medical records, according to the bill.
Abortions performed under the rape and incest exceptions must report it to the sheriff in the county in which the abortion was performed within 24 hours. Physicians must tell the patient they will report the rape before the abortion is performed.
Physicians are also required to maintain a copy of the patient's records for seven years after an abortion is performed under the exception. Failing to do so would be a felony with up to two years of imprisonment and a $10,000 fine on the physician, according to the bill.
Pregnant women upon whom an abortion is performed in violation of the law can seek actual and punitive damages against the violator.