For the second time in a month, the fate of the last abortion clinic in Missouri hangs on a judge’s ruling.

The state health department rejected the St. Louis Planned Parenthood’s permit application Friday morning. The expected move does not immediately affect the clinic’s operations because of a court order allowing it to operate during an ongoing legal dispute with Missouri officials. But a state judge could effectively revoke that permission.

Planned Parenthood and representatives of the state’s health department had a hearing Friday morning in front of Circuit Judge Michael Stelzer. The Associated Press reported that Stelzer would issue a directive outlining the next steps, which could determine whether the clinic will ultimately be allowed to continue performing abortions. The judge did not say when that would come.

In a news conference Friday, health department director Randall Williams said the agency denied the clinic’s application because they have corrected only four of the 30 deficiencies that inspectors identified. He again cited concerns over multiple “failed abortions," which required additional procedures, and a patient who suffered life-threatening complications. The issues have been central to the state’s case against Planned Parenthood.

If the facility closes, Missouri would return to an era before the Supreme Court legalized abortion nationwide with its 1973 decision in Roe v. Wade. Friday’s court date was another installment in the legal standoff that has unfolded in the weeks since the health department threatened to shutter the clinic.

After the agency’s latest announcement, Colleen McNicholas, an OB/GYN at the clinic, criticized the Missouri governor and the health department director. She said her staff would continue providing abortion services “for as long as the court protects our ability to do so.”

“This decision signals the true motive behind this license renewal mess that has left patients in limbo, uncertain about their health care: to ban abortion without ever overturning Roe v. Wade," McNicholas said in a statement.

But Williams did concede to the clinic’s demand that its doctors not be forced to perform a pelvic exam on patients at least three days before they receive an abortion. Planned Parenthood’s physicians complained that this requirement effectively subjected women to two pelvic exams — one 72 hours before the procedure, when the state required it, and another on the day of the procedure, when the clinic deemed it medically necessary. Critics have called the rule “state-sanctioned sexual assault.” Earlier in the week, Planned Parenthood had announced its intention to defy the regulation.

“I am issuing an emergency rule today that Planned Parenthood can defer the pelvic exam to the day of surgery if, in their estimation, using their clinical judgment, they think there is a medical reason they should do that,” Williams said. “Because we do not want patients having two pelvic exams.”

The health agency’s formal denial means the clinic could choose to argue its case in front of the state’s independent hearing board, made up of four commissioners — three of whom were appointed by the Democratic former Gov. Jay Nixon. In early June, current Gov. Mike Parson (R) appointed the fourth, a man who was once publicly disciplined for supporting an anti-abortion organization, the AP reported.

The end of abortion services at the health center would mark a milestone in the state-by-state battle over abortion rights, one that has intensified in 2019 as conservative lawmakers across the country have pushed increasingly strict bans on the procedure. Advocates worry that Missouri could be a harbinger of future efforts to close clinics, especially in the handful of states that have only one abortion facility left.

Like many other states, Missouri already had restrictive laws on its books. Last month, Parson signed into law a measure that bans abortions after eight weeks of pregnancy and provides no exceptions for victims of rape or incest, only for medical emergencies. Parson said on Twitter that the bill would make Missouri “the most Pro-Life state in the country!”

Antiabortion activists and groups have applauded the governor’s efforts.

“While abortion supporters continue to scramble to play the victim and blame others for their deficiencies, Missouri state leaders are standing firm and fighting for the protection of women and their babies, both born and unborn,” Susan Klein, the executive director of Missouri Right to Life, said in a statement following Stelzer’s May 31 ruling.

On June 6, an effort to overturn the state’s ban spawned another court fight. After Missouri’s Republican secretary of state rejected two referendum petitions that would have repealed the law, the American Civil Liberties Union, which backed one of the initiatives, sued the top election official. The backer of the other initiative said he’d do the same.

Other existing laws, such as ones that require women to undergo counseling and then wait 72 hours before they can get an abortion, long made it difficult for poor patients and rural residents to access services. And a requirement that doctors have partnerships with local hospitals limited the number of physicians who could perform the procedure.

“The rules around providing abortion care have been so onerous and egregious over the decades that it hadn’t really mattered that states like Alabama and Missouri started passing outright bans,” said David Eisenberg, the medical director for Planned Parenthood of the St. Louis Region and Southwest Missouri. “Abortion has been effectively regulated out of existence in Missouri.”

At a May news conference, Parson told reporters that the state had “serious health concerns” about the St. Louis clinic. The health department said its inspection found concerns over patient safety, including the center’s noncompliance with the requirement that doctors give patients a pelvic exam three days before the procedure, and what the agency called “failed surgical abortions.”

The agency also asked to interview current and former physicians about the problems it found, but Stelzer ruled earlier this month that testimony from the clinic’s non-staff doctors wasn’t necessary. Williams said Planned Parenthood has demonstrated an “unprecedented refusal” to cooperate, and Parson said it shouldn’t get any “special treatment.”

Planned Parenthood, meanwhile, said its clinic “has maintained 100 percent compliance” with the law, and Eisenberg said adhering to the pelvic exam regulation meant they had to administer the invasive checkup twice, once days before the procedure and again on the day of it. Doing so is an “insulting, totally unnecessary and medically unethical treatment,” he said.

Even if the health center is no longer able to provide abortions, it will remain open, offering testing for sexually transmitted diseases, cancer screening and other services. Even so, the organization warned that more than 1 million Missouri women of reproductive age would live in a state with no access to abortion services.

There is a facility just across the Mississippi River from St. Louis, in Granite City, Ill., a state that has moved in the opposite direction, passing more abortion protections. Missouri patients now forced to travel to Granite City will probably drive on a highway that illustrates the deep divide in the abortion debate. This spring, the Granite City facility, Hope Clinic, bought a billboard along Interstate 55 that reads, “Welcome to Illinois, where you can get a safe, legal abortion.”

Clarification: This story has been updated to clarify the health department’s pelvic exam requirement. Before it changed its policy on Friday, the state required women to receive one pelvic exam at least 72 hours before an abortion. Planned Parenthood has argued that this rule effectively forces women to undergo the exam twice, once three days before the procedure and again on the day of, when the clinic argues it is medically necessary.

Correction: On one instance, a previous version of this story referred to Judge Michael Stelzer as a federal judge. He is a state judge for the Missouri Circuit Court.

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