Despite Bans and Anti-Choice Violence, Independent Abortion Clinics Fight to Keep Their Doors Open

In the fight for abortion rights, independent clinics are the unsung heroes.

Even before the end of Roe v. Wade in 2022, independent clinics provided the majority of abortion care in the United States, more than hospitals, private physicians and even Planned Parenthood. Since the Dobbs decision, despite the closing of dozens of indie clinics in states where total abortion bans went into effect, they’ve still provided about 58 percent of abortions in the country, according to data from Abortion Care Network (ACN)’s latest report, released last month.

Entire regions depend on independent clinics for abortion care, with over 60 percent of indie clinics located in states with extremely restrictive abortion laws. Often, women’s access to later-term abortion also depends on indies, which make up the majority of clinics providing abortion care in the second and third trimesters of pregnancy.

Despite their crucial role providing care—often to women in healthcare deserts where reproductive care is hard to come by—indies don’t have the institutional support, name recognition and fundraising capacity of hospitals and national health centers. This lack of visibility can make it difficult for patients to find them and hard for them to secure the support they need to keep their doors open.

“Operating like community health centers, these clinics often lack fair reimbursement rates, state or federal funding, and support from grants or charitable donations,” said Nikki Madsen, co-executive director of Abortion Care Network, a national organization that works to connect independent clinics and share resources, in a press release about ACN’s new report.

Meanwhile, since Roe v. Wade was overturned, 14 states have introduced abortion bans sweeping enough to force all the clinics in those states to close.

At the same time, independent providers often operate in the U.S. states most hostile to abortion rights. Without the support and security of a large hospital, independent clinics are especially vulnerable to threats, harassment and even physical violence from antiabortion protesters.

Ona Marshall is a co-owner of the EMW Women’s Surgical Center in Louisville, Ky., which for 10 years was the only clinic in Kentucky, providing 98 percent of abortion care in the state, before the clinic was forced to close after the Dobbs decision under Kentucky’s total abortion ban. When the clinic was still open, Marshall and other providers faced incredibly aggressive protesters harassing patients. Some protesters were there five days a week, combined with groups of individuals coming from other states and traveling around the country to harass patients and volunteers.

“The protesters are very organized and effective,” Marshall said at an online panel on Dec. 3 hosted by Abortion Care Network.

At EMW, Marshall was used to protesters bringing loudspeakers and large signs with images of the clinic’s doctors. The protesters—some of whom were the same people at Jan. 6, according to Marshall—chased patients on the sidewalk to and from their cars, took photos of license plates and tried to invade the clinic itself. A crisis pregnancy center (CPC) also operated out of the building right next door to EMW, participating in the protesters’ tactics and misleading and misdirecting patients trying to obtain abortion care.

The Louisville city government helped by passing an ordinance creating a narrow 10-foot “buffer zone,” marked by yellow lines from the curb to the clinic’s front door, where patients, companions, staff and volunteers could enter the clinic free from assault (but still vulnerable to verbal harassment from protesters). However, EMW was only allowed the buffer zone after five years and three petitions, and the buffer zone was difficult to enforce.

Before Dobbs, EMW was a regional center where patients traveled from other states to get abortions. Now, there is not a single independent abortion clinic left in Kentucky or most of the nearby states.

With EMW closed down, Marshall and the other providers have shifted their focus to advocacy. When I spoke to Marshall on the phone last month, she told me that she’s been working on a number of education and media campaigns to raise awareness about the state of reproductive health in the state of Kentucky and the need for legal abortion. 

In February 2024, Marshall and other advocates took physicians and medical students to the state Capitol to hold a press conference about the dangers of abortion bans, as well circulating a letter that doctors and other health professionals signed calling for a repeal of the statewide ban. (More than 70 percent of medical students in Kentucky would consider medical school in a different state because of Kentucky’s abortion ban, according to a survey from the Kentucky Reproductive Freedom Fund, part of the ongoing trend of OB-GYN students refusing to do their residencies in states where they can’t give patients abortion care.)

“We just try to keep it in the news as much as possible,” she said. “And we do our part with policy reform and working with the legislators to see what we may be able to do and keep the pressure on.” At the clinic, they’re trying to retain as much infrastructure as possible in case it’s ever allowed to reopen.

Since the end of Roe, at least 76 independent clinics have been forced to close or stop providing abortions, according to data that ACN has collected. Seventy percent of these clinics were located in the South or Midwest, in states where maternal and reproductive care is already hard to find.

One of the clinics shut down was Clinic for Women in Indianapolis. The Dobbs decision meant that the clinic couldn’t operate any longer in Indiana, owner and director LaDonna Prince decided to move the clinic one state over to Danville, Ill., where she found a new location. In Illinois, abortion is legal and covered under Medicaid.

Danville, meanwhile, is only a one-hour drive from Indiana. Prince received a grant to launch a media campaign, and is planning to set up billboards in the metropolitan area of Indianapolis telling women that they can go to the new clinic in Illinois, called Affirmative Care Solutions, for abortions. Illinois also has the advantage of requiring only one clinic visit for an abortion—unlike nearby state Ohio which requires two—making it an easier option for women who have to commute for care.

“We’re hoping that will be a big draw to Illinois,” Prince said. Even though the Indianapolis Clinic for Women is shut down, the clinic’s website is updated with information redirecting patients to the new clinic in Danville.

Prince was set to open the new clinic in January 2023. But it turned out that moving to a new state was only half the battle.

Even in Illinois where abortion is heavily protected thanks to the 2019 Reproductive Health Act,(RHA). some members of Danville’s city council in Danville were not welcoming.  In a tie-vote broken by the Mayor, the city passed an unlawful abortion ban in violation of RHA. The ACLU of Illinois and Feminist Majority Foundation worked with the clinic and community members to sound the alarm, and Illinois Attorney General Kwame Raoul issued a powerful statement making clear the law was not in effect and that local governments cannot limit access to abortion.

Then, in April, a 73-year-old antiabortion extremist rammed his car repeatedly into the walls of the clinic building, destroying the entryway, waiting room and a rear wall before planning to burn down the building with gas cans. He became trapped in the rubble and was convicted of attempted arson, but the devastating attack has delayed the clinic’s opening by more than a year and a half.

Aside from the half a million dollar’s worth of damage, Prince has struggled to find contractors to repair the building. Some plumbers and construction workers haven’t been willing to drive from more solidly pro-choice parts of the state like Chicago and Champaign. Local contractors, after learning that it was an abortion clinic needing the repairs, have simply hung up.

The attack on the clinic has also given Prince a new level of anxiety about showing up for work. “It took away a piece of me, and a piece of the security I had,” she said.

Antiabortion harassment is nothing new for her; at Clinic for Women, she dealt with a CPC next door, hostile protesters and even one disturbing instance of a woman following her home and taking pictures of her children in the front yard.

Still, the most recent act of violence has shattered her sense of security within the four walls of the clinic.

“Safety is paramount,” Prince said. “Everyone needs to go home at night.”

But adding to the cost of clinic repairs is the money needed to install bullet-resistant panels in the walls and other safety measures that would have once seemed absurd but now seem indispensable.

“We need to be at our best so we can provide our best services to these women,” she said. But “the unknown is a little terrifying to me.”

Hiring security guards is also expensive, but Prince told me that she’s hoping to find volunteers able to act as clinic escorts, field patient phone calls, schedule appointments and make calls to find resources like gas money and hotel rooms for patients who need financial help so the doctors can focus on their work. 

“When patients are there, we have to give them 100 percent of our attention,” she said. “And sometimes looking for resources of that nature can be a little cumbersome when you’re trying to do patient care and you’ve got somebody on the phone who’s crying, who needs help.” 

Besides costing the clinic millions of dollars and denying Indiana women close access to critical abortion care, the terrorist attack and shutdown for repairs meant the clinic had no source of income for more than a year, so Prince is hoping for volunteers to chip in as temporary receptionists while the new clinic gets off the ground. The clinic is also trying to raise money through a GoFundMe. Even sending the clinic a supportive postcard, she said, makes a huge difference for staff morale, “because we’re stretched really, really thin.”

duVergne Gaines, director of the Feminist Majority Foundation’s National Clinic Access Project, said, “Now more than ever, we need to mobilize communities and local and state legislators to prioritize protecting clinic staff and patients by passing better laws like state Freedom of Access to Clinic Entrances laws and sound and buffer zones, providing grants for clinics especially for security and infrastructure, and aggressively prosecuting violent extremists.” 

Fighting for the legal right to open a clinic, facing threats from protesters and going to work worried about violence are stressors that other healthcare providers simply don’t have to deal with. For many independent clinics, being one of only a few clinics in a state also means high patient traffic and long hours for doctors, starting work early in the morning and going home late at night. 

When Prince was operating Clinic for Women in Indianapolis, one of the antiabortion protesters’ tactics was calling the clinic and pretending to be patients to make appointments, thinking that the clinic would turn real patients away if all the slots were filled. “But it was a moot point, because we never turned patients away,” Prince said. “We work very long days, sometimes, because we could have 40 patients in a day. So you just go in knowing that it’s going to be a long day, but you’ve got to provide this service to these women.”