Abortion rights activists rally in protest against six-week abortion bill at the old Florida Historic Capitol on March 29, 2023. (Photo by Briana Michel/Florida Phoenix, States Newsroom.)

Dr. Cherise Felix says a recent patient yelled and swore at her before eventually hugging her, grateful she would no longer have to carry the planned-for baby that had died inside her.

Felix provides abortions at Planned Parenthood clinics in Florida, which on May 1 banned abortion at six weeks’ gestation. She was able to see this patient, who was about 17 weeks pregnant, because of the abortion law’s limited health exceptions. But before coming to the clinic, the miscarrying patient was turned away by another OB-GYN, something Felix said happens regularly since the ban.

“They’re having to walk around with these deceased pregnancies, and they were wanted pregnancies, but their physicians aren’t comfortable treating them because the laws are so precarious and they’re always changing,” Felix told States Newsroom.

She is among many doctors in Florida who say the six-week ban has disrupted reproductive health care and among more than 850 doctors who this week endorsed a citizen-led ballot initiative to restore abortion rights. If it receives 60% of the vote, Amendment 4 would legalize abortion until fetal viability, and after for fetal and maternal health issues.

But if it fails, advocates predict reproductive health access will further decline throughout the Southeast, which depended on Florida for access after Roe v. Wade was overturned in 2022. The solid wall of abortion bans in the South includes near-total bans in Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Oklahoma, Tennessee, Texas and West Virginia; six-week bans in Florida, Georgia, and South Carolina; and a 12-week ban in North Carolina.

“I’m hopeful that it passes — 60% is a lot to hope for, but I think the alternative is scarier,” Felix said. “If you allow government interference into your exam room, it’s not just going to stop with this one thing. … It starts creeping into those people who never thought they’d be at Planned Parenthood … but it starts to spread into other areas of health care.”

How reproductive access has already changed in Florida and beyond

OB-GYNs and hospitals remain confused and scared about Florida’s abortion ban, despite guidelines from the health department saying it does not preclude miscarriage management or the treatment of specific conditions.

On a recent press call organized by Floridians Protecting Freedom, which is leading the Yes on 4 campaign, Miami-based OB-GYN Dr. Chelsea Daniels said she recently saw a patient who was eight weeks pregnant and had four ultrasounds from four different doctors all showing her pregnancy was not growing, but they still wouldn’t perform the abortion.

“She needed an abortion because each passing day put her at increased risk of infection and bleeding,” said Daniels, who works for Planned Parenthood of South, East and North Florida. “I understand why these four other doctors turned her away. They were afraid. The exception criteria are so narrow that they can’t possibly address every single case. So if a doctor gets audited and the state challenges their judgment, they could be fined, lose their license, and sent to jail. This case was medically very clear, but legally murky.”

Felix came to work for the same affiliate as Daniels from Tennessee, which banned abortion in 2022. She told States Newsroom it’s been a full-circle career moment, having slowly watched the politicization of routine miscarriage procedures like dilation and curettage, a common method of clearing a patient’s uterus when the body has not expelled all the fetal tissue. She said that when she first became an OB-GYN and was working at a hospital, miscarriage management was provided in the hospital, then with ethics committee support, then referred out to high-risk specialists, and, in her recent experience, sequestered to abortion clinics.

“Miscarriage management is still management of abortion,” Felix said. “It’s just a spontaneous abortion. So that code gets submitted to insurance companies; it raises flags.”

Providers told States Newsroom they are also turning away many patients who are seeking to end their pregnancies after six weeks, which is before many people realize they are pregnant. Planned Parenthood and independent abortion clinics in Florida have developed systems to help coordinate patients with clinics in other states, which typically involves complex variables that lead patients to all corners of the U.S.

Daniels told States Newsroom she travels to Virginia and Maryland most weekends to perform abortions, where many of her patients end up being from Florida.

“I was just there over the weekend, and the number of Floridians I saw, where I’m here in Miami, and they’re coming from Fort Lauderdale, and we both had to travel 1,200 miles to be able to both provide and receive care, when in reality we live and work down the road from each other,” Daniels said. “It feels like a farce, like it’s hard to believe that this is the world that we live in.”

Daniels believes many people are continuing pregnancies they wanted to end, and says no single state would be able to accommodate the nearly 100,000 patients that had abortions in Florida in 2023. Many people can’t travel because they lack time off, child care, and money, and abortion funds have been drying up. Some people turn to online abortion-pill websites, like Aid Access, whose founder, Dr. Rebecca Gomperts, told States Newsroom they have been averaging 700 medication abortion regimens sent to Floridians each month since the ban went into effect, a slight decline from prior months.

Planned Parenthood clinics have so far been able to stay open in Florida, pivoting to other essential reproductive health care. But some independent abortion clinics hanging on until November say they might have to shutter, which would likely further reduce access to the limited types of abortion care that are still permitted under Florida law.

Amber Gavin, vice president of advocacy and operations at A Woman’s Choice clinics, said their Jacksonville clinic has been seeing only about a third of the patients they were seeing before the ban and that they’ve been referring many Florida patients to their North Carolina and Virginia locations. Before the ban, she said the clinic was seeing patients from all over, but especially Alabama, Georgia, Louisiana, Mississippi, South Carolina, Tennessee and Texas.

She told States Newsroom A Woman’s Choice has been encouraging patients to vote for Amendment 4 because she’s not sure the clinic can stay open if it fails, given their declining revenue.

“Our staff is doing everything they can, but it’s really taxing and demoralizing to have to turn patients away or tell them that we don’t have funding,” Gavin said.

Hurdles to restoring abortion access

To succeed, Florida’s Amendment 4 will need to clear a super-majority of the vote, the highest threshold for an abortion-rights ballot measure to date. Floridians Protecting Freedom additionally faces mounting opposition from Republican Gov. Ron DeSantis’ administration that includes trying to force a terminal cancer patient’s story off the airwaves and launching a voter-fraud investigation that has fueled a lawsuit from anti-abortion advocates to kick the amendment off the ballot, even as Floridians have already begun casting votes. Recent surveys have found the amendment polling at 60%, but others have it falling short.

The leaders of the abortion-rights ballot effort — who say they’ve so far raised $90 million — see a path to victory despite these many obstacles, which also include two recent hurricanes. The campaign has intentionally made its messaging nonpartisan, acknowledging the need to win over supporters of Republican presidential nominee Donald Trump in order to get the necessary 60% of the vote. At a recent press conference sponsored by the Fairness Project, which committed $30 million this cycle to support abortion-rights ballot measure campaigns across the nation, Floridians Protecting Freedom campaign director Lauren Brenzel objected to the idea of the state’s amendment being a turnout mechanism for Democratic presidential nominee Kamala Harris and down-ballot campaigns.

“We have an abortion ban that will stay in effect for decades to come if we don’t end it this November,” Brenzel said. “[The amendment] has no relation to any other race. It’s because policy is failing the people of Florida right now.”

Anti-abortion advocates leading the vastly outspent Vote No on 4 campaign have tried to mobilize religious Floridians against the proposed amendment, which would limit abortion at viability, the imprecise moment when a growing fetus can survive outside the uterus, estimated at 24 weeks. The anti-abortion campaign argues that the amendment’s unspecified cutoff and broad health exceptions could lead to “unlimited” abortions.

In full, the amendment reads: “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 healthcare provider.”

The Vote No on 4 campaign did not respond to a request for comment.

Soon after Yes on 4’s “Caroline” ad first aired on Oct. 1, the Florida Department of Health sent cease-and-desist letters to local television stations, calling it “categorically false” and threatening to criminally charge broadcasters who continued playing the ad. In it, a 40-year-old Tampa mom of a 4-year-old recounts discovering late-stage brain cancer while about 17 weeks pregnant with her second child in April 2022. Doctors gave her a year to live with aggressive treatment but very little time if she remained pregnant. Caroline, who asked not to use her last name to protect her privacy, credits surpassing her one-year prognosis with the abortion she says she wouldn’t have been able to get today.

“When I had mine, I said to my husband, ‘Could you imagine if we lived in a state that didn’t offer this?’” Caroline told States Newsroom. “I was in the ICU. I wasn’t able to fly; I wasn’t able to drive. And then after that is when everything fell apart in Florida. It’s just been very eye-opening for me that it could be that cruel.”

The state has argued that Caroline’s situation would not have been precluded under the ban. But doctors have reported that the law is difficult for hospitals to interpret and requires extra consultations that take time patients might not have. The state surgeon general’s cease-and-desist letters asserted that the two-physician requirement “is waived in the case of an emergency medical procedure.” But many doctors say it’s unclear what would count as an emergency medical procedure. The federal lawsuit that the abortion-rights ballot organizers filed against the state health department to stop threatening broadcasters includes an affidavit from an OB-GYN and maternal health specialist who says she wouldn’t have given Caroline the abortion in Florida.

“While the termination was medically necessary because the cancer was terminal, the abortion would not have saved the patient’s life and therefore could be illegal under Florida law,” wrote Dr. Shelly Hsiao-Ying Tien, who practices at Planned Parenthood of South, East and North Florida and at Genesis Maternal-Fetal Medicine in Tucson, Arizona.

A federal judge last week temporarily barred the DeSantis administration from coercing television stations to stop airing the ads. Court records show that the DeSantis administration was directly behind the effort threatening the broadcasters with criminal charges. Caroline told States Newsroom she wants to “use my voice while I have it,” noting she temporarily lost the ability to speak when she was first diagnosed with brain cancer.

“That was one of the first things that I lost in this diagnosis, and luckily I have it again, for now,” Caroline said. “I want to do this for my daughter, so that she can have the same rights as me and my mother, and for all the cancer patients that are diagnosed. For everyone.”