Planned Parenthood is making good on its threats to pull out of a federal family planning program, announcing Wednesday it will end its participation Aug. 19, barring a court ruling in its favor — a move expected to leave 1.6 million low-income women who rely on its services scrambling to figure out whether they need new providers.

In a letter to U.S. Court of Appeals for the 9th Circuit, Planned Parenthood attorneys said its affiliates had planned to refuse federal funds — but not drop out of the program — while its challenge of new Trump administration prohibitions on abortion referrals or “directed counseling” made its way through the courts. Planned Parenthood leaders have said it is morally and medically wrong to not be able to offer their clients complete medical information.

But Health and Human Services officials recently required all participants in the program, known as Title X, to sign a pledge by Aug. 19, saying they would make a “good faith” effort to comply with the rule. HHS Deputy Assistant Secretary Diane Foley said Planned Parenthood’s proposal to remain in the program without doing that is “inconsistent.”

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Planned Parenthood attorney Alan E. Schoenfeld wrote that as a result and with “deep regret,” the grantees “now have no option but to withdraw from the Title X program.”

Alexis McGill Johnson, acting president of Planned Parenthood said in a statement, “We refuse to let the Trump administration bully us into withholding abortion information from our patients.”

The result of the agency’s withdrawal will vary greatly by state, said Erica Sackin, a spokeswoman for the organization. Some states have pledged to make up the funds. But in others where that isn’t the case, especially rural areas where providers can be many miles from one other, the effect is likely to be “chaos,” she said.

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In Ohio, a mobile health center that provides testing for sexually transmitted disease, birth control and education, will probably have to shut down, Sackin said. In Vermont, where Planned Parenthood is the only Title X provider in the entire state, women would be referred elsewhere. Some Planned Parenthood affiliates may waive fees or offer discounts on a sliding scale, she said.

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“Planned Parenthood health centers are doing everything we can to make sure patients can still get care but it would be a mistake to think there won’t be changes,” Sackin said.

The Trump administration’s rollout of the rule, which requires a bright line of separation between abortion and non-abortion services, has been mired in confusion as various court actions have made the implementation dates a moving target. In addition, the rule’s language and the HHS guidance have been unclear about what can and cannot be said in counseling sessions.

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Abortion providers have called the changes a “gag rule” that would prevent them from offering women counseling that includes discussion of abortion. HHS has said “nondirective” counseling would be allowed, but there has not been clarity on what that means.

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On Friday, HHS issued guidance providing some more information, saying that while family planning providers “are prohibited from referring for abortion as a method of family planning, referral for abortion because of an emergency medical situation is not prohibited.”

It also states a provider “may not provide pregnancy options counseling which promotes abortion or encourages persons to obtain abortion, although the project may provide patients with complete factual information about all medical options and the accompanying risks and benefits.”

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Clinics may also provide pregnant women with “a list of comprehensive healthcare providers (including prenatal care providers), including some (but not the majority) who perform abortion as part of a comprehensive healthcare practice. However, this list cannot serve as a referral for, nor identify those who provide abortion — and Title X providers cannot indicate those on the list who provide abortion."

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Near the end of its guidance, HHS singled out Planned Parenthood in an unusual criticism: “To the extent that Planned Parenthood claims that it must make burdensome changes to comply with the Final Rule, it is actually choosing to place a higher priority on the ability to refer for abortion instead of continuing to receive federal funds to provide a broad range of acceptable and effective family planning methods and services to clients in need of these services.”

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