After the Trump administration announced that providers who receive money from the nation’s only dedicated family planning program can’t refer people for abortions, Planned Parenthood made national headlines by leaving the program.

But while Planned Parenthood is anti-abortion activists’ biggest bogeyman, the bulk of American abortions are actually performed by small, independent abortion clinics. Those providers are also quietly leaving the Title X program — and without the name-brand recognition, political sway, or fundraising firepower of a national network, they’re fighting to keep their services cheap and available.

Many serve poor and marginalized patients in rural areas, a mission that has never been exactly lucrative or easy. In several states, clinics must navigate labyrinthine abortion restrictions that can eat away at their budget or threaten to shut them down altogether.

“Anytime there’s an attack [on abortion rights], it hurts all clinics,” said Jay Thibodeau, communications director for the Abortion Care Network, a membership organization for independent abortion providers. “But indies don’t always have the same sort of resilience and safety net that Planned Parenthood or hospitals have.”

These clinics are also already an endangered species: Between 2012 and late 2018, the number of independent clinics in the United States fell by about 28 percent, to 370, the Abortion Care Network found. Still, independent abortion providers from Colorado to Maine have announced they plan to leave Title X rather than comply with what they see as an unethical “gag rule” on a legal procedure.

“I think that abortion rates are going to go up.”

It’s hard to know exactly how many independent abortion clinics are departing, since the National Family Planning & Reproductive Health Association — which represents dozens of Title X providers — is not formally tracking that number. However, every Title X-funded clinic in the Abortion Care Network is leaving the program. All 31 of them.

When Lisa Leach, director of New Hampshire’s Joan G. Lovering Health Center, was hired in May, she planned to expand LGBTQ health care, and focus on pelvic floor health and behavioral health. But only two months later, the Trump administration announced that providers that receive money from the Title X family planning program, like the Lovering Health Clinic, were barred from referring patients for abortion.

The clinic was forced to leave Title X, and its budget has been slashed by about 20%. It is already illegal to use federal taxpayer dollars to pay for abortions, except in very limited circumstances; instead, Title X helps provide STI tests, cancer screenings, and birth control to about 4 million low-income people nationwide.

So instead of expanding the clinic’s services, Leach has found herself weighing whether to cut its walk-in hours or its sliding fee scale, which almost half of the clinic’s patients use.

“How do you add services to the center, where I have to focus right now on just keeping the base, base services going?” Leach said. “We really didn’t think that this was going to happen. It was in the back of our minds that we had to have a backup plan, but we were really all very shocked when it came out as it did.”

She went on, “Independent centers that struggle to keep the lights on and pay their staff and just — we give so much good health care and people don’t know that we’re here.”

Advocates of the changed rules say they’ll ensure that taxpayer money doesn’t “intermingle” with funds that go to abortions, but the changes to Title X are also often seen as an attempt to sideswipe Planned Parenthood’s funding. (The organization provides about 35% of all U.S. abortions, according to the Abortion Care Network.)

It worked: The organization’s decision to leave Title X rather than comply with the administration’s new rules was a devastating blow to both the Title X network — since Planned Parenthood serves about 40% of its patients — and Planned Parenthood itself, which is believed to be surrendering about $60 million. On Monday, Planned Parenthood officials announced that they would have to close two Ohio clinics, neither of which offered abortions.

In addition to stopping referring patients for abortions, Title X providers must now also financially separate any abortion-related services from their other offerings — and physically separate the two by March 2020. For clinics that don’t perform abortions, that’s less of a concern. Many Title X providers told VICE News that they intend to stay in the program, out of a need to keep their doors open and serving as many patients as possible.

Few abortion clinics, however, can financially swing setting up a whole new office.

“We are basically a one-building, one-location office, so we would have had to either rented or bought another location in order to do abortion services,” said Dalia Vidunas, executive director of Equality Health Center, New Hampshire’s oldest abortion clinic. Even if a clinic were able to open up a second location for abortions, it would not be able to refer Title X patients to itself.

Equality Health Center received about 11% of its yearly budget from Title X before it departed the program. Since then, it’s had to cut staff. As of late August, Vidunas was evaluating whether the clinic needs to slash hours and its sliding fee scale, and if it can continue taking Medicaid. More than 30 percent of the clinic’s patients don’t have insurance, she said.

“I am honestly scared to death for the residents of New Hampshire and for everyone else,” Vidunas said. “STDs and HIV are going to increase, and you’re also going to have an increase in unintended pregnancies because people aren’t going to be able to get birth control at a reduced cost or a level that is affordable. And I think that abortion rates are going to go up.”

Almost every clinic staffer that VICE News spoke to said that they plan to bump up their fundraising to compensate for the loss of Title X. Planned Parenthood can, at least, rely on its fame when soliciting donations. But few people have heard of Cedar River Clinics, a chain of independent abortion providers in Washington state, for example.

“It’s a financial hit,” Mercedes Sanchez, Cedar River’s director of communications, said of losing Title X funding. “While Washington is a very supportive, great state, fundraising is still a challenge for independent clinics because we don’t necessarily have the resources to be out there in a big way. And it’s even more challenging for clinics in hostile states.”

Lawmakers in Washington and New Hampshire have promised to try to use state funding to make up for the Title X (though after the latter set aside money to do so, Republican Gov. Chris Sununu vetoed the budget for unrelated reasons).

But Sharon Lewis, executive director of Women’s Health Center of West Virginia, barked out a laugh when asked if she expects her state to help her abortion clinic cope with losing Title X. The Women’s Health Center has been part of Title X for at least three decades, Lewis said; the program paid for about 15% of its budget.

“This state is not a friendly state to abortion or reproductive health,” said Lewis, whose clinic is the only one providing abortions in West Virginia.