In some states, including Wyoming, Louisiana, and Alabama, independent abortion clinics are the only sources of abortion care, meanwhile they are the last clinics remaining in four states: Kentucky, Mississippi, North Dakota, and West Virginia.

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A new report details the crucial role independent abortion clinics play in ensuring access in parts of the country most hostile to abortion rights—and the struggle for them to stay open.

Anti-choice state-level restrictions have led to a decrease of over 32 percent in the number of independent abortion clinics in the United States since 2012, according to the Abortion Care Network report. As of November, 26 independent abortion clinics have closed this year—double the number that closed in 2018.

Independent abortion care providers represent about 25 percent of facilities offering abortion care nationwide, yet they provide a little more than half of abortion procedures, according to the report. Three out of five people in the United States who receive abortion care do so at an independent clinic, and these facilities provide about 58 percent of all abortion procedures, compared to 37 percent at Planned Parenthood, 3 percent in hospitals, and 1 percent in private physician’s offices.

In some states, including Wyoming, Louisiana, and Alabama, independent abortion clinics are the only sources of abortion care. Six states have only one abortion provider, and independent providers operate the last clinic remaining in four of those states—Kentucky, Mississippi, North Dakota, and West Virginia. Planned Parenthood operates the only clinics in the other two states, Missouri and South Dakota.

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“Meaningful abortion care in the United States truly depends on independent abortion care providers,” Nikki Madsen, executive director of the Abortion Care Network, told Rewire.News. “Independent abortion providers have been providing the majority of care since Roe was established. The vital role they play in making abortion access a reality in this country is really an untold story.”

Though 88 percent of abortions are performed in the first trimester, barriers to accessing abortion care, like forced waiting periods, bans on insurance coverage of abortion, or needing to travel to receive care, can cause people to seek abortion care later in pregnancy, said Alison Dreith, deputy director of Hope Clinic for Women, an abortion clinic in Granite City, Illinois. For those needing abortion care after the first trimester, many turn to independent clinics, which operate 62 percent of clinics that provide abortions after the first trimester.

“Patients seeking care have to face so many burdens to get to us, whether it’s travel or arranging child care—add the rising cost of their procedure as they get later in pregnancy, and continuing to have to save up that money because it is not covered by insurance,” Dreith said.

Independent clinics represent 69 percent of all clinics that provide care at and after 16 weeks of pregnancy and 77 percent of clinics providing care at and after 19 weeks of pregnancy, according to the report. In Arkansas, Nevada, Oklahoma, and Georgia, the only providers of surgical abortion are independent clinics, and without them, abortion access in these states would be limited to medication abortion within the first ten to 11 weeks of pregnancy.

“When there are increased barriers, people need more access to later care,” Madsen said.

Increased state regulations on abortion providers since Republicans came into power in state legislatures a decade ago have forced many clinics to shut their doors, Madsen said. This year alone, state legislatures in the South and Midwest have passed 58 abortion restrictions, and lawmakers in five states have passed near-total abortion bans, though none are in effect.

Medically unnecessary targeted regulations on abortion providers, or TRAP laws, hit independent clinics especially hard because they are not financially able to make the changes necessary to comply, Madsen said. Lawmakers in 11 states have banned private insurance coverage for abortion except in cases of life endangerment, so independent clinics are working to keep costs low for their patients, while also dealing with increased costs of security in hostile regions where protesters often harass patients and staff.

“It’s a combination of factors, and it’s not simple, but it is a targeted effort by politicians and extremists to close clinics,” Madsen said.

Independent abortion providers also lack the visibility, institutional support, and financial resources of other providers, like Planned Parenthood. While Planned Parenthood health centers are 501(c)(3) nonprofits, which allows them to engage in some lobbying efforts, 85 percent of independent clinics are not, which limits their ability to influence policy decisions.

“All of our staff are front line staff,” Dreith said. “They are seeing patients every day, and so we oftentimes don’t get to talk about our unique experiences to legislators. Then when it comes to these new policies, we are first to shut down, because we also can’t raise the funds to offset the cost of fixing our building or otherwise complying with that law.”

Because they lack the resources of other, larger providers, independent clinics rely on volunteers and community support to stay open.

“This is why we need the public and communities to get involved because they really need their community’s support,” Madsen said.