Abortion opponents have turned to different tactics since the Supreme Court legalized most abortions half a century ago, from imposing 24-hour waiting periods to banning late-term procedures to requiring minors to get permission.
But in the wake of Kermit Gosnell, the Philadelphia abortion doctor convicted in May of first-degree murder in the deaths of three babies, the anti-abortion movement has increasingly aimed its fire at the brick-and-mortar. On Friday, Texas became the 16th state to tighten regulations on abortion clinics in the past three years, more than doubling the number of states with what opponents call "targeted restrictions on abortion providers."
The mostly recently affected states range from Republican strongholds like North Dakota and Alabama to political battlegrounds like Ohio and Wisconsin. Only six of the 42 abortion clinics in Texas meet the stricter standards that require them to operate like surgical centers, meaning dozens could close. North Carolina lawmakers are also debating tougher licensing requirements.
"The adoption of these regulations is really about shutting clinic doors, which in a sense is easier than trying to overturn Roe v. Wade or to ban abortion," said Elizabeth Nash, state issues manager for the Guttmacher Institute, a research group that favors abortion rights. "We're moving into new territory and very extreme restrictions."
The anti-abortion movement's success, however, stems in part from activists making the case that tougher clinic regulation is a mainstream cause to improve women's safety. In Texas, the new rules are wrapped around a ban on abortions after 20 weeks, a limit that most Americans support, according to recent polling. The latest United Technologies/National Journal Congressional Connection Poll found Americans favor banning late-term abortions 48 to 44 percent. A majority of women surveyed in the poll supported the ban after 20 weeks.
Peggy Nance, president of the Concerned Women for America Legislative Action Committee, billed the new Texas law as "very limited, common ground legislation."
"The pro-life movement is at its core is about protecting the unborn child and protecting women, and we believe women deserve better than abortion," said Mallory Quigley, spokesman for the Susan B. Anthony List, an anti-abortion group. "If a clinic shuts down, there's one less decrepit clinic that's endangering women."
It's a public relations strategy that seems to be working, even as an 11-hour fillibuster by Texas Sen. Wendy Davis has energized Democrats in her state. At a time when the Republican Party is trying to refute Democratic attacks that abortion limits constitute a "war on women," increasing regulations on clinics can be framed as a positive blow for public health. "These are not viewed as restricting abortion so much as protecting women's health," said Republican pollster Kellyanne Conway. "Women think it is outrageous that tattoo parlors have more operational regulations than abortion clinics."
By arguing that public opinion is out their side, abortion opponents are using a strategy similar to that of gay rights advocates, who point to increasing acceptance of gay marriage in the polls. The public remains closely divided over abortion, however, forcing opponents to rely on the grisly details of the Gosnell case and Republican control of most state capitals to win the argument for tougher clinic oversight. Texas Gov. Rick Perry, a former and possibly future Republican presidential candidate, said earlier this year that his goal was to make abortion "a thing of the past." Mississippi Gov. Phil Bryant, also a Republican, called the new regulations "the first step in a movement, I believe, to do what we campaigned on: to say that we're going to try to end abortion in Mississippi." There's one abortion clinic in the state.
These declarations by anti-abortion officeholders suggest the rules are aimed more at regulating clinics out of business than at improving patient safety. Virginia boasts one of the toughest laws in the country, putting abortion clinics on the same category as hospitals.
After surviving arson, bullets and pipe bombs during its 40 years in existence, the Hillcrest Clinic in South Hampton Roads closed in April, in part because of the new regulations. "I was there for 28 years and I can recall transporting one person to a hospital who had a reaction to a medication -- which is a risk in a dental office too," said the former director, Suzette Caton.
Rosemary Codding, director of a Northern Virginia abortion clinic suing the state, opened the door to one of the biggest scofflaws in her office: the janitor's closet. The cramped space isn't big enough under the stricter guidelines, and the washer and dryer need to be in a separate room. Meeting the stricter standards, which also dictate the size of the hallways, parking lot and outdoor awning, would cost the Falls Church Healthcare Center an estimated $1 million.
"How in the world would this improve the safety of women?" Codding demanded during a recent tour, peering into the closet of cleaning supplies. "I feel very strongly the state is sacrificing women's health to a political agenda, and that's unconscionable."
The new rules apply only to the 20 clinics in Virginia offering first-trimester abortions, since the state already requires later-term procedures to be done in a hospital. Clinics have to meet the same construction standards as hospitals built after 2010, even though existing hospitals do not have to comply retroactively. Less than 0.3 percent of women getting abortions need to be hospitalized, according to the Guttmacher Institute.
Virginia's new law holds abortion clinics to stricter standards than medical offices that perform outpatient procedures like colonoscopies, oral surgery and even liposuction.
"The objection is that these regulations will do nothing to help women reach a higher standard of medical care," said Anna Scholl, director of ProgressVA, a liberal group that fought the new rules for abortion clinics. "They are not connected to the medical reality of the services those centers are providing. A woman getting a mammogram doesn't need extra room in the hallway for another gurney."
The Falls Church clinic has sent only two patients to the hospital in the last decade; one wasn't getting an abortion. The clinic also offers pregnancy tests, gynecological exams, birth control and flu vaccines. The clinic is much smaller than a typical hospital, with only 11 employees and 5,000 square feet of space.
The state health board initially voted to grandfather in existing clinics, but Virginia Attorney General Ken Cuccinelli rejected that decision and warned board members they could be personally liable for legal costs if they were sued. The state health commissioner resigned in protest.
Cuccinelli is now the Republican nominee for governor. His office said he was only following the law passed by state lawmakers in 2011, which he believes precluded the board from waiving the rules for existing abortion clinics.
"When it comes to advising on and enforcing Virginia's laws in my role as attorney general, my personal opinion about them doesn't matter," Cuccinelli said in a written statement. "Whether I like them or don't like them, my job is to impartially uphold our laws."
It's quiet at Falls Church Healthcare Center on a recent afternoon, making it seem far removed from the heated rhetoric at rallies in Washington, D.C., Austin, and Raleigh in recent weeks. Inside a dumpy, three-story building, the clinic tries to present a cheerful setting with freshly painted cream-colored walls and boxes of pink and purple plastic flowers in the waiting room.
While women in medical scrubs padded by, Codding pointed to a number of rooms and fixtures that would flunk the new guidelines. The 50-year-old building lacks a central ventilation system, and the ceiling tiles are no good. The tiny staff lounge doesn't have a shower or separate lockers. The armchairs in the patient lounge will probably need to be separated with privacy curtains, but she's not sure. "We have a year to figure all of this out," she said. "It just makes no sense."