UPDATE, November 13, 2019, 4:09 p.m.: Ohio’s health department has granted a license to Women’s Med Center, the last abortion clinic in the Dayton area. The clinic can resume providing surgical abortion care, according to the American Civil Liberties Union. The legal battle against the state’s written transfer agreement requirement will continue. 

Abortion clinics in Ohio and Missouri are fighting to stay open in the face of burdensome and medically unnecessary state regulations that threaten access to reproductive health care, testing the limits of the constitutional right to an abortion.

The last abortion provider in the Dayton, Ohio, area, Women’s Med Center, is trying to avoid closure after the Ohio Department of Health revoked its license in April for failing to meet strict regulations designed to shut down abortion clinics. The clinic has postponed surgical abortions while providing medication abortion care amid its legal challenge to the health department’s regulatory enforcement, the Associated Press (AP) reported.

Local activists and pro-choice advocates told Rewire.News that the closure of Women’s Med Center, which in 2018 served more than 2,000 patients, would have an outsized effect on vulnerable populations that make up much of the region.

Dayton has a large population of people of color and those with low incomes. There are around 35,000 women of reproductive age living in Dayton, Ohio’s sixth-largest city, according to the U.S. Census Bureau. Nearly 43 percent of Dayton’s population is Black. The median household income in Dayton is $30,128, less than half that of the national median household income.

“Restrictions to access of safe and legal health-care options by attempting to close the Dayton clinic are unconstitutional, undue burdens on patients,” District 10 Indivisible for All, an anti-racist activist group in the Dayton area, said in a statement to Rewire.News. “People of color, people in poverty, and other marginalized communities are most impacted when this happens. Women will be forced to travel to other cities or states to receive care. This can be a barrier for low income and some people of color.”

The Ohio Supreme Court in late October declined to hear an appeal from Women’s Med Center, placing its fate in the hands of a federal judge after the clinic sought a restraining order to temporarily block the state from enforcing those regulations, which it argues unconstitutionally infringes on the right to an abortion. An attorney for the clinic told the AP last week that the federal judge would rule quickly on the temporary restraining order.

The Ohio Health Department is denying the clinic a license based on its inability to comply with a state law requiring abortion clinics to have a written patient transfer agreement with a local hospital in the case of an emergency. Advocates say the law is medically unnecessary and doesn’t do anything to ensure patient safety, but rather is designed to make it too difficult for abortion providers to operate and force them to close down.

The law requires that patient transfer agreements be obtained from private hospitals within 30 miles of the facility.

“The fact that Ohio places the decision of whether a clinic can stay open in the hands of a private corporation is completely bonkers,” said Gabriel Mann, a spokesperson for NARAL Pro-Choice Ohio. “You have to find a privately owned non-religious facility, and in some cases they practically don’t exist.”

In the Dayton area, the only private hospitals that could sign the medically unnecessary transfer agreement are Kettering Health Network, which was founded by the Seventh-Day Adventist Church, and Premier Health, which is partially owned by a Catholic organization. Many Catholic-run hospitals have proven hostile to reproductive health care. NARAL Pro-Choice Ohio has launched a campaign to put pressure on Kettering Health Network and Premier Health to sign the agreement.

“There’s no reason why the hospital can’t just sign this piece of paper, which costs the hospital nothing, and requires them to take no action other than just to continue serving patients as they do,” Mann said.

Over the summer, more than 3,300 people signed a petition asking Premier Health to sign the transfer agreement and help protect abortion access in Dayton, the Dayton Daily News reported. Premier Health in a statement to WOSU Radio said that because of the organization’s governing documents, “We have long been—and continue to be—prohibited from entering into certain arrangements, which include transfer agreements with this type of provider.”

Without Women’s Med Center, there would be just six clinics in the state that provide surgical abortions. Mann said since former Ohio Gov. John Kasich (R) took office in 2011, the number of abortion clinics in the state has been cut in half due largely to the regulatory scheme designed and passed into law by Republican majorities. Gov. Mike DeWine (R) has pledged to continue Kasich’s assault on abortion access.

“All together, the actions of the legislature, the extremist groups, and the governor, and the way that Governor Kasich and now Governor DeWine have ordered around the health department to increase the number of annual inspections on clinics, all of these factors combine to make it very difficult for providers,” Mann said.

The Ohio law is one example of how anti-choice legislators have placed targeted regulations on abortion providers, referred to as TRAP laws. According to the Guttmacher Institute, a reproductive and sexual health research organization, Ohio is one of 24 states with laws that regulate abortion providers beyond what is necessary to ensure the safety of patients.

Women’s Med Center’s battle to remain open comes as the fate of last operating abortion clinic in Missouri hangs in the balance due to that state’s similarly strict regulatory process for abortion providers.

An administrative hearing to determine whether the Missouri Health Department can revoke the license for Reproductive Health Services of Planned Parenthood in St. Louis concluded last week after state regulators claimed this year that an audit revealed “deficient practices” at the clinic, but didn’t provide many specifics. Reproductive rights activists have accused Missouri officials of moving “the goalposts” in their regulatory push to end legal abortion in the state.

Missouri could become the first state with no abortion provider since Roe v. Wade established the constitutional right to abortion in 1973.

The question of whether strict regulations on abortion clinics like those in Ohio and Missouri violate the constitutional right to an abortion is one that will be considered by the U.S. Supreme Court when it hears the June Medical Services v. Gee case, which challenges a Louisiana law requiring abortion doctors to have admitting privileges at a local hospital.

The case will likely revisit the precedent set in Whole Woman’s Health v. Hellerstedt, in which the Supreme Court ruled in 2016 that parts of a Texas law that caused widespread clinic closures constituted an “undue burden” on the right to an abortion.