Two additional Ohio abortion clinics—a Planned Parenthood in Cincinnati and the Women’s Med Center in Dayton—are in legal limbo as a result of new restrictions signed by Gov. John Kasich, which could block access to safe, legal abortion for residents in the western half of the state.

The new restrictions have to do with whether a clinic can obtain a transfer agreement with an area hospital that would accept the clinic’s patients in an emergency, and whether a clinic can get a “variance” to exempt it from this requirement. Added to the state budget this summer, the regulations ban public, taxpayer-funded hospitals from entering into such transfer agreements, and allow the state health department to rescind a variance for any reason.

Public hospitals are already required to care for all emergency room patients, including any patient who has a complication from an abortion, regardless of whether a clinic has a transfer agreement. Only 0.18 percent of abortions in Ohio in 2012 resulted in any complications, which may or may not have necessitated an emergency room visit. “Having a transfer agreement is nothing more than paperwork,” Kellie Copeland, executive director of NARAL Pro-Choice Ohio, told Rewire. “The notion that public hospitals were ever spending money on non-therapeutic abortions is a solution in search of problem. It wasn’t happening.”

Rewire previously reported that if all of the Ohio clinics threatened with closure are forced to close, the state would only have nine clinics left; it had 14 at the beginning of the year. Now that number could be as low as seven. Three clinics—in Cleveland, Cuyahoga Falls, and Toledo—already closed voluntarily this year amid regulatory pressures, and four now face uncertain fates: one in Toledo, one in Dayton, and two in the Cincinnati area.

The Cincinnati Planned Parenthood’s transfer agreement with the University of Cincinnati’s UC Health center was not renewed. Despite the fact that UC Health is legally a private hospital, hospital executives feared the law would still apply to them because UC Health is run by a public university. Planned Parenthood’s request for a variance that would let them stay in operation regardless is still pending.

The Women’s Med Center in Dayton’s recent application for a variance is also pending, and the Women’s Med Center in the Cincinnati suburb of Sharonville is appealing the health department’s rejection of its variance request.

Capital Care Women’s Center in Toledo remains open while appealing a state closure order after the public University of Toledo Medical Center preemptively rescinded its transfer agreement to avoid controversy.

The Cincinnati Enquirer reports that if both Cincinnati-area clinics close, the region would be the largest metropolitan area in the country without an abortion clinic. But Toledo and Dayton are also both in danger of losing their sole providers. If this happened, only women in central Ohio, near Columbus, or in northeastern Ohio, near Cleveland or Akron, would have access to abortion in their state without traveling great distances. And Ohio’s mandatory 24-hour waiting period requires making multiple trips to the clinic, putting an extra burden on women whose jobs, families, or financial straits restrict their ability to travel.

“You’re looking at hundreds of miles of round-trip travel required, which is ultimately an insurmountable barrier for some,” said Copeland. “It doesn’t matter if abortion remains legal if it’s so inaccessible you can’t get one when you need one.”

Already, some women in Ohio are crossing the border to Michigan to obtain abortions because of clinic closures in their own state. The Cleveland provider that closed this year, run by Dr. Martin Ruddock, also moved to Michigan, in part because Ohio’s laws regarding abortions performed after 20 weeks made it difficult to tend to patients with fetal abnormalities, Copeland said.

Nine states have transfer agreement requirements like Ohio’s, but Ohio is the only state that limits which type of hospital can enter into them. This restriction is especially tricky for clinics, because many private hospitals are Catholic-affiliated and want nothing to do with abortion services.

“We’re not talking about patient safety,” said Copeland. “We’re talking about regulatory red tape and, frankly, regulatory abuse.”