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Little Rock Family Planning Services v. Rutledge

United States District Court, E.D. Arkansas, Western Division

August 6, 2019

LITTLE ROCK FAMILY PLANNING SERVICES, et al., PLAINTIFFS
v.
LESLIE RUTLEDGE, in her official capacity as Attorney General of the State of Arkansas, et al., DEFENDANTS

          PRELIMINARY INJUNCTION

          Kristine G. Baker United States District Judge.

         Before the Court is a motion for a temporary restraining order and/or preliminary injunction filed by separate plaintiffs Little Rock Family Planning Services (“LRFP”) and Thomas Tvedten, M.D., on behalf of himself and his patients (Dkt. No. 2).[1] The Court held a hearing on July 22, 2019, and entered a temporary restraining order on July 23, 2019 (Dkt. No. 83). In the temporary restraining order, the Court held plaintiffs' request for a preliminary injunction under advisement. For the reasons set forth below, the Court grants plaintiffs' request for a preliminary injunction.

         Plaintiffs bring this action seeking declaratory and injunctive relief on behalf of themselves and their patients under the United States Constitution and 42 U.S.C. § 1983 to challenge three Acts passed by the Arkansas General Assembly: (1) Arkansas Act 493 of 2019, which bans abortion “where the pregnancy is determined to be greater than 18 weeks, ” as measured from the first day of a woman's last menstrual period (“LMP”) in nearly all cases (“Act 493”); Arkansas Act 619, which prohibits a physician from intentionally performing or attempting to perform an abortion “with the knowledge” that a pregnant woman is seeking an abortion “solely on the basis” of: a test “indicating” Down syndrome; a prenatal diagnosis of Down syndrome; or “[a]ny other reason to believe” the “unborn child” has Down syndrome (“Act 619”); and (3) Arkansas Act 700 of 2019, which provides that “[a] person shall not perform or induce an abortion unless that person is a physician licensed to practice medicine in the state of Arkansas and is board-certified or board-eligible in obstetrics and gynecology.” (“Act 700” or the “OBGYN requirement”). This Court has jurisdiction under 28 U.S.C. §§ 1331 and 1343(a)(3).

         I. Procedural History

         Plaintiffs filed their complaint and motion for a temporary restraining order and/or preliminary injunction on June 26, 2019 (Dkt. Nos. 1, 2). The challenged Acts were to take effect on July 24, 2019. The Court held the hearing on plaintiffs' motion for temporary restraining order and/or preliminary injunction on July 22, 2019 (Dkt. No. 78).

         In response to a motion for expedited prehearing discovery filed by defendants, the Court instructed the parties to meet and confer regarding any outstanding discovery requests and to file a joint status report on July 12, 2019 (Dkt. No. 34). On July 10, 2019, plaintiffs filed a supplemental declaration from Jason Lindo, Ph.D., and in response defendants sought to strike the supplemental declaration or to extend the time to respond to the motion for temporary restraining order and/or preliminary injunction (Dkt. Nos. 37, 38). Plaintiffs opposed the motion to strike the supplemental declaration and the request to extend the time to respond to the motion (Dkt. No. 39). The Court denied the motion to strike or request for additional time to respond to the motion, observing in part that any alleged prejudice would be limited and mitigated if the Court “treats plaintiffs' motion as one for temporary restraining order, then such an order-whether granted or denied-would expire 14 days from the date it is entered, and the Court may permit all parties to address further the merits of this expedited matter prior to a hearing on plaintiffs' request for a preliminary injunction.” (Dkt. No. 41, at 2).

         The parties timely filed their joint status report on July 12, 2019, and reported that they required the Court to resolve three remaining discovery disputes (Dkt. No. 40). In that same status report, the parties represented that certain information would be turned over contingent upon the entry of a protective order that was still being negotiated by the parties. The Court then entered an order denying without prejudice defendants' motion for expedited prehearing discovery, resolving only the three remaining discovery disputes the parties had been unable to resolve at that time (Dkt. No. 42).

         On July 18, 2019, defendants filed a renewed motion for expedited prehearing discovery (Dkt. No. 56). In that motion, defendants argued that, because plaintiffs insisted upon an “unreasonably broad definition of ‘confidential information, '” the parties could not agree on the terms of a protective order, and therefore defendants had not received agreed-upon discovery (Id., at 1). In response, plaintiffs pointed out that they sent a proposed protective order to defendants on July 10, 2019, but defendants did not respond until July 15, 2019, with a counterproposal (Dkt. No. 60, at 4). Plaintiffs responded on July 16, 2019, rejecting the counterproposal (Id.). Defendants did not file a renewed motion until July 18, 2019, after filing a written response to the motion for temporary restraining order and/or preliminary injunction. On July 19, 2019, the Court denied defendants' renewed motion for expedited prehearing discovery and entered a protective order (Dkt. Nos. 69, 70).

         On Saturday, July 20, 2019, a day after the deadline for disclosing rebuttal exhibits and witnesses in advance of the July 22, 2019, hearing had elapsed, defendants filed a new declaration that totaled 272 pages, with attachments; plaintiffs also filed a supplemental rebuttal witness list (Dkt. Nos. 73, 74). Then, on Sunday, July 21, 2019, plaintiffs filed a motion to strike certain declarations introduced by defendants, including the declaration filed on Saturday, July 20, 2019 (Dkt. No. 75). Also on Sunday, July 21, 2019, defendants filed a motion to strike certain declarations introduced by plaintiffs and to strike plaintiffs' reply brief (Dkt. No. 76).

         The hearing was held on July 22, 2019 (Dkt. No. 84). Plaintiffs called Frederick Hopkins, M.D., Linda Prine, M.D., Lori Williams, Dr. Lindo, and Thomas Tvedten, M.D. Defendants called Janet Cathey, M.D., Tumulesh K.S. Solanky, Ph.D., Donna Harrison, M.D., and Judy McGruder. Plaintiffs recalled Dr. Prine for rebuttal, after which defendants did not cross examine her. Plaintiffs also recalled Dr. Lindo for rebuttal, and likewise defendants did not cross examine him on his rebuttal testimony. Neither party identified additional witnesses they wished to have called. Furthermore, neither party utilized the full time granted by the Court to question the witnesses who appeared at that hearing.

         The day after the July 22, 2019, hearing, plaintiffs filed a notice of correction of the record in which they attached a supplemental declaration by Dr. Lindo that corrected duplicate entries within Excel files that had been produced to defendants (Dkt. No. 79, at 1). Defendants then filed a motion to strike this declaration, arguing that the Court should strike the latest declaration and allow defendants further discovery by deposing Dr. Lindo (Dkt. No. 80). The Court denied defendants' motion to strike this declaration and their request to depose Dr. Lindo (Dkt. No. 96).

         On July 23, 2019, the Court entered a 14-day temporary restraining order enjoining the enforcement of Acts 493, 619, and 700. On July 25, 2019, defendants filed a motion for expedited preliminary-injunction-proceeding discovery, in which defendants sought the Court's permission to propound discovery requests on plaintiffs regarding Planned Parenthood of Arkansas and Eastern Oklahoma's (“PPAEO”) ability to provide abortions in Little Rock, PPAEO's efforts to provide surgical abortions in Arkansas, building requirements applicable to surgical abortions, and data on out-of-state abortion clinics (Dkt. No. 86). Defendants also sought permission to issue a Federal Rule of Civil Procedure 30(b)(6) deposition notice on PPAEO (Id.). Plaintiffs responded to the motion for expedited discovery (Dkt. No. 92), and the Court denied defendants' motion (Dkt. No. 97).

         At the hearing, plaintiffs objected to defendants' request to introduce as a hearing exhibit in this matter the entire record from Planned Parenthood Arkansas and Eastern Oklahoma v. Jegley, No. 4:15-cv-00784-KGB, on the basis that defendants failed to refer to, or move to introduce, any specific portions of that record in response to plaintiffs' motion for temporary restraining order and/or preliminary injunction here. The Court entered a written Order recounting the parties' positions with respect to Jegley and the current case, declining defendants' oral motion to incorporate the entire record from Jegley into this matter, and directing the parties to cite to specific portions of the Jegley record for the Court's consideration in this matter (Dkt. No. 94).

         Defendants also requested a second hearing, and the Court denied this request (Dkt. No. 111). The Court noted, in part, that the matters defendants wished to raise at a second hearing were known to defendants at the July 22, 2019, hearing and that the defendants had an opportunity to cross examine plaintiffs' witnesses on these matters at that time (Id.). In ruling on plaintiffs' motion for preliminary injunction, the Court has considered the record before it as of August 6, 2019. Further, given the limited nature of a preliminary injunction order, the Court declines to strike the declarations filed by any party and instead will give them the weight to which they are entitled at this stage of the proceedings. See Wounded Knee Legal Def./Offense Comm. v. Fed. Bureau of Investigation, 507 F.2d 1281, 1286-87 (8th Cir. 1974).

         II. Findings Of Fact

         The Court makes the following findings of fact.[2]

         1. Charlie Browne, M.D., a board-certified obstetrician-gynecologist (“OBGYN”) offers an affidavit in support of plaintiffs' motion (Dkt. No. 2, at 24-28; Decl. of Charlie Browne, M.D., ¶ 1). Dr. Browne is a Clinical Assistant Professor at the University of Washington Medical Center, Department of Obstetrics and Gynecology in Seattle, Washington, and Clinical Faculty at Pacific Northwest University College of Osteopathic Medicine in Yakima, Washington (Id.). He is also the Medical Director of All Women's Care in Seattle Washington, the Medical Director of All Women's Health in Tacoma, Washington, and the Director of Second-Trimester Services of Planned Parenthood of Greater Washington & Northern Idaho (Id.). In these positions, Dr. Browne provides abortion care and other gynecological services (Id.).

         2. Dr. Browne avers that, based upon his experience and training, a medical provider does not need to be a board-certified or board-eligible OBGYN to have the education, training, and skills necessary to provide safely and competently abortion care (Decl. of Charlie Browne, M.D., ¶ 6). In his experience, there is no difference in the abilities, qualifications, or skills of non- OBGYN practitioners and OBGYNs who have received the necessary training to provide abortion care (Id.).

         3. Dr. Browne further avers that being a board-eligible or board-certified OBGYN does not make an abortion provider any more equipped to handle the “rare complications that may arise from an abortion.” (Id., ¶ 7). Dr. Browne explains that “in the rare event of a serious complication, the patient would need to be transferred to a hospital for emergency care, regardless of whether the physician providing abortion care is a board-certified OBGYN.” (Id.). In his experience, serious complications arising from either medication or surgical abortions are rare (Decl. of Charlie Browne, M.D., ¶ 7).

         4. From August 2010 to December 2010, Dr. Browne provided abortion care for LRFP approximately once every four to six weeks for two to three days at a time (Id., ¶ 8). Between 2011 and July 2012, he also provided abortion care at LRFP approximately two to three weeks per year (Id.). After 2012, Dr. Browne had to stop providing abortion care at LRFP since it takes him approximately six to seven hours to travel to LRFP from his home and because the time away from his home was disruptive professionally (Id., ¶¶ 9-10).

         5. Dr. Browne also avers that providing abortion care at LRFP was difficult and stressful due to harassment he experienced while working at the clinic (Decl. of Charlie Browne, M.D., ¶ 11). Every time Dr. Browne traveled to LRFP, he encountered protestors attempting to block the entrance to LRFP's parking lot (Id.). He also states that the harassment and stigma he experienced in Arkansas was “far more prevalent and aggressive than any [he had] experienced as an abortion provider elsewhere.” (Id., ¶ 12). For these reasons, Dr. Browne has not returned to LRFP for the past seven years (Id., ¶ 13).

         6. Dr. Browne states that LRFP staff reached out to him in March 2019 to see if he would be willing to provide abortion care at LRFP when the OBGYN requirement is set to take effect (Decl. of Charlie Browne, M.D., ¶ 14). Dr. Browne has agreed to do so but only for two to three days in July 2019 (Id.). He cannot commit to providing care after that time given his professional and personal obligations in Seattle, Washington (Id.).

         7. Janet Cathey, M.D., a board-certified OBGYN licensed to practice medicine in Arkansas and Oklahoma, has presented her declaration in support of plaintiffs' motion (Dkt. No. 2, at 36-41, Decl. of Janet Cathey, M.D.)). Dr. Cathey avers that she provides medical services, including medication abortion, at PPAEO health center in Little Rock, Arkansas (Id., ¶ 1).

         8. In early 2018, Dr. Cathey was asked by PPAEO to provide reproductive health care services at PPAEO's health center in Little Rock (“PPAEO Little Rock”), and in May 2018, she began working at the health center in Little Rock (Id., ¶ 3).

         9. At LRFP's Little Rock health center, Dr. Cathey provides family planning services, transgender care, and medication abortions (Id., ¶ 4). She also has administrative responsibilities, including overseeing clinical staff, teaching medical students, and acting as director of Planned Parenthood Great Plains' (“PPGP”) transgender care program (Decl. of Janet Cathey, M.D., ¶ 4). Since she started in this position through April 30, 2019, she has provided 229 medication abortions (Id., ¶ 5).

         10. Dr. Cathey is one of only two physicians providing medication abortion at PPAEO's Little Rock health center (Id., ¶ 6). The other physician, Dudley Rodgers, M.D., is a board-certified OBGYN who provides only medication abortions approximately one day per week (Id.). Dr. Rodgers is semi-retired and does not provide medical care anywhere else, due in part to health issues that prevent him from providing patient care for long hours or multiple days a week (Id.).

         11. Dr. Cathey currently provides medical care at PPAEO's Little Rock health center three days per week for approximately eight to ten hours a day (Decl. of Janet Cathey, M.D., ¶ 7). She also works as a medical consultant for Social Security disability reviews and completes PPAEO administrative responsibilities two other days per week (Id.). Dr. Cathey's administrative responsibilities include providing non-clinical services to her transgender patients, mentoring medical students regarding abortion care, transgender care, and other medical care, including gynecological procedures (Id.). Dr. Cathey also avers that she expects her non-clinical responsibilities to increase (Id.).

         12. Dr. Cathey avers that, during the three days that she provides patient care, her schedule is at capacity (Decl. of Janet Cathey, M.D., ¶ 8). Due to patient demand, Dr. Cathey is planning to add another half day a week to provide patient care, including care to patients seeking medication abortions, transgender care, and family planning (Id.). She states that providing care three and a half days per week “is the absolute maximum amount of time” she can devote to patient care (Id.).

         13. Dr. Cathey also notes that she cannot take on additional hours to provide medical care because of physical limitations resulting from a spinal cord injury she sustained in a 2009 car accident (Id., ¶ 9). Because of her injuries, she originally stopped providing patient care, and though she now practices medicine, she continues to have physical restrictions (Decl. of Janet Cathey, M.D., ¶ 9).

         14. Dr. Cathey also avers that she sees a significant number of transgender and family planning patients and that she is the only physician at PPAEO's Little Rock health center who provides care for these patients (Id., ¶ 10). It is Dr. Cathey's understanding that the only other health center in Arkansas that maintains a dedicated transgender care program is the University of Arkansas for Medical Sciences (“UAMS”) clinic, which provides transgender care “only one half day per week.” (Id.).

         15. In sum, due to her other personal and professional responsibilities, Dr. Cathey cannot see any more medication abortion patients other than those she is able to see in three and a half days per week (Id., ¶ 11).

         16. Dr. Cathey also avers that, based upon her experience, she does not believe that requiring all abortion providers to be board-certified or board-eligible OBGYNs provides “any benefit whatsoever to patients.” (Decl. of Janet Cathey, M.D., ¶ 12). She notes that clinicians from a range of specialties, including family medicine, can become trained to provide abortion care (Id.). She maintains that there is nothing about being a board-certified or board-eligible OBGYN that makes a physician better, safer, or more effective at providing abortion care (Id.). Dr. Cathey testified at the hearing that, during her time at UAMS, she observed the training of OBGYN residents, and she noted that very few of them received training in abortion care (Dkt. No. 84, at 203:1-2). She also noted that most, but not all, of the OBGYN residents were able to provide miscarriage management by the end of their residency (Id.).

         17. Dr. Cathey states that many family medicine physicians and other clinicians undergo training to provide safely abortion care (Decl. of Janet Cathey, M.D., ¶ 13). She further states that family medicine medical students are “just as skilled and qualified to provide abortion care as the OBGYN students.” (Id., ¶ 14).

         18. Dr. Cathey states that “restricting the number of clinicians who can provide abortion in the state to only board-certified or board-eligible OBGYNs will actually harm patients, as it can force patients to unnecessarily delay their access to care or prevent them from obtaining an abortion altogether.” (Id., ¶ 15 (emphasis in original)).

         19. Dr. Cathey notes that there are already very few abortion providers in Arkansas, which she attributes to “the intense stigma and harassment that abortion providers face here.” (Id., ¶ 16). When her children were younger and in school, Dr. Cathey did not want to provide abortions because she feared the harassment that her children would likely face (Id.).

         20. At the hearing, defendants' counsel asked Dr. Cathey if she would perform an abortion if the woman seeking the abortion indicated that she was seeking an abortion because the fetus was transgendered or based upon the fetus' race (Dkt. No. 84, at 201:1- 202:9). Defendants did not ask Dr. Cathey about her capacity to provide abortions for PPAEO or about the capacity of PPAEO's new facility in Little Rock. Defendants did not argue that they did not have enough time to question Dr. Cathey, nor did they ask the Court to direct Dr. Cathey to answer any questions.

         21. Lori Freedman, Ph.D., an associate professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco, offers her declaration in support of plaintiffs' motion (Dkt. No. 2, at 47-57, Decl. of Lori Freedman, Ph.D.). Dr. Freedman's work focuses on qualitative health research, clinician training and practice, medical ethics in reproductive health, and health care practices of religiously affiliated institutions (Id., ¶ 3). She has studied barriers to the provision of abortion care (Id.). In particular, she has researched “why doctors with abortion training do not integrate abortion care into their practice post-residency.” (Id.).

         22. In her opinion, in addition to violence and harassment, the intense stigmatization of abortion providers makes it difficult, if not impossible in certain areas, to find and retain abortion providers (Decl. of Lori Freedman, Ph.D., ¶ 4).

         23. Dr. Freedman explains that “no-abortion” policies in private practice groups, hospital maintenance organization (“HMOs”), and hospitals often prevent physicians from providing abortions (Id., ¶ 11). She also states that physicians are often asked to sign contracts stating that they will not provide abortions at the offices of their practice and that they will not provide abortions offsite (Id.).

         24. Of five doctors who had been asked to be medical directors at an abortion clinic, four of them told Dr. Freedman that they had declined because their own group practices would not permit it (Id.). Additionally, Dr. Freedman states that, in her research, she has encountered situations where senior physicians threatened to ostracize younger physicians who performed abortions (Decl. of Lori Freedman, Ph.D., ¶ 12). She also states that physicians interviewing for post-residency positions have told her that they fear broaching the subject of abortion with potential employers (Id.).

         25. Dr. Freedman also avers that physicians who provide abortions frequently lose referrals from medical providers who oppose abortion, thereby placing their practices in jeopardy (Id., ¶ 13). Additionally, Dr. Freedman notes that doctors may decline to provide abortions because they worry about losing existing patients who are opposed to abortion (Id.).

         26. Furthermore, Dr. Freedman points out that physicians who wish to perform abortions often must choose whether to maintain a general obstetrics and gynecology (“OBGYN”) practice or provide abortions, but not both (Decl. of Lori Freedman, Ph.D., ¶ 14).

         27. Dr. Freedman also notes that abortion providers are routinely ostracized in their communities through acts such as being denied membership to social organizations and the bullying of their children at school (Id., ¶ 15). She also states that physicians cite the effects of picketing by protestors as a reason not to provide abortions (Id.).

         28. Dr. Freedman states that violence against abortion providers is an ongoing concern and that, as recently as 2015, there were three murders and nine attempted murders of abortion clinic staff in the United States (Id., ¶ 18 (citing Nat'l Abortion Fed'n, 2017 Violence and Disruption Statistics 6 (2017), available at https://prochoice.org/wp-content/uploads/2017-NAF-Violence-and-Disruption-Statistics.pdf)). She states that the threat of violence “significantly deters many physicians from providing abortion and increases physicians' reluctance to associate themselves with abortion clinics and providers in any way.” (Decl. of Lori Freedman, Ph.D., ¶ 19).

         29. Dr. Freedman states that Arkansas “fits the profile of a state hostile to the provision of abortion care where abortion providers are likely to experience the highest levels of stigma and harassment.” (Id., ¶ 20).

         30. Dr. Freedman also states that further evidence she has reviewed indicates that abortion providers in Arkansas experience extreme levels of harassment and effects of stigma, including being forced by their partners to choose between private practice and continuing to provide abortion care, being subjected to picketing and harassment, and being unable to attract qualified OBGYNs or other providers to work at their clinics (Id., ¶ 21).

         31. Dr. Freedman avers that abortion providers are less likely to be able to resist the effects of stigma and harassment in Arkansas cities that lack a professional community that normalizes abortion care (Id., ¶ 23).

         32. Stephanie Ho, M.D., a board-certified family medicine physician, offers her declaration in support of plaintiffs' motion (Dkt. No. 2, at 89-103; Decl. of Stephanie A. Ho, M.D.)).

         33. Dr. Ho states that she cannot become a board-certified or board-eligible OBGYN because she did not complete a residency in OBGYN and that she cannot do so now due to the time and resources necessary to conduct a residency at this stage of her career (Id., ¶ 7).

         34. Dr. Ho further states that, at the time she submitted her declaration, surgical abortions could not be performed at PPAEO's Fayetteville health center (“PPAEO Fayetteville”) because that facility did not meet the state's requirement governing facilities where surgical abortions are performed (Id., ¶ 10).

         35. Dr. Ho explains that Arkansas law requires women who seek abortion care to come to the health center to receive certain state-mandated information in person from a physician and then to wait at least 48 hours before having an abortion (Id., ¶ 14).

         36. Dr. Ho further explains that a patient seeking medication abortion services must therefore come to the health center for one appointment, and at least 48 hours later, she must return to take a mifepristone pill and be given four misoprostol pills to administer at home (Decl. of Stephanie A. Ho, M.D., ¶ 15). The patient must also make a follow-up appointment for approximately two weeks later (Id.).

         37. Dr. Ho further states that medication abortion is extremely safe and that 97.4% of medication abortion cases are successful under the regimen just described (Id., ¶ 16 (citing Daniel Grossman et al., Effectiveness and Acceptability of Medical Abortion Provided Through Telemedicine, 118 Obstetrics & Gynecology 296, 300 (2011))).

         38. Dr. Ho notes that a woman who takes mifepristone at a PPAEO health center has access to a 24-hour hotline number that she can call with any questions or concerns and that patients are provided with the name and number of a contracted OBGYN physician who has agreed to serve as the collaborative medical doctor to PPAEO abortion providers in Fayetteville and Little Rock (Id., ¶ 17).

         39. Dr. Ho states that most patients who call the hotline “simply need reassurance that their symptoms (like bleeding and cramping) are normal and will subside.” (Decl. of Stephanie A. Ho, M.D., ¶ 18). In the “exceedingly rare case” that the nurse or physician on the hotline believes that immediate medical treatment is necessary, the patient is referred to the nearest emergency room, one of PPAEO's physicians is notified, and health center staff follow up with the patient within 24 hours (Id.).

         40. Dr. Ho notes that, during the course of her medical career, she has performed procedures that are much more complicated and have higher complication rates than medication abortion, including: induced and managed labor, delivery of babies, and tubal ligations (Id., ¶ 20). Dr. Ho also states that the national risk of maternal mortality associated with live birth is approximately fourteen times higher than that associated with induced abortions (Id. (citing Elizabeth G. Raymond & David A. Grimes, The Comparative Safety of Induced Abortion and Childbirth in the United States, 119 Obstetrics & Gynecology 215 (2012))). She also notes that, in Arkansas, the maternal mortality rate is even worse, with Arkansas ranked 44th in the nation for maternal mortality compared to other states in 2018 (Id. (citing United Health Foundation, 2018 Health of Women and Children Report (2018), https://www.americashealthrankings.org/lea rn/reports/2018-health-of-women-and-children-report/state-summaries-arkansas)).

         41. Dr. Ho further states that PPAEO drafted a job opening for a board-certified or board-eligible OBGYN to provide abortion care at the Fayetteville health center (Id., ¶ 23). This posting was listed on social media, and a letter was sent to all identified OBGYNs in Arkansas (Decl. of Stephanie A. Ho, M.D., ¶ 24).

         42. PPAEO also took out an ad in the Journal of the Arkansas Medical Society seeking a board-certified or board-eligible OBGYN (Id., ¶ 25). PPAEO staff personally contacted physicians to see if they would provide abortion services (Id.).

         43. In May 2019, Kathleen Paulson, M.D., a board-certified OBGYN, contacted PPAEO to state that she would be willing to provide medication abortion at the Fayetteville health center on a volunteer basis if the OBGYN requirement were to go into effect (Id., ¶ 26).

         44. To date, no other OBGYNS have responded to PPAEO's efforts to locate a board-certified or board-eligible OBGYN willing to provide medication abortion at PPAEO's health centers (Decl. of Stephanie A. Ho, M.D., ¶ 29).

         45. Dr. Ho states that she has experienced stigma as an abortion provider in Arkansas, including being informed by a potential employer that the potential employer was not interested in being associated with an abortion provider (Id.).

         46. Frederick W. Hopkins, M.D., M.P.H., a board-certified OBGYN, offers his declaration in support of plaintiffs' motion (Dkt. No. 2-1, at 119-136; Decl. of Frederick W. Hopkins, M.D., M.P.H.).

         47. Dr. Hopkins points out that, during his OBGYN residency, he did not receive any formal training in abortion care and that “[a]bortion care is not a requirement to complete an OBGYN residency, and most OBGYN residencies did not provide that training.” (Id., ¶ 13).

         48. Dr. Hopkins states that “[l]egal abortion is one of the safest medical procedures in the United States” and that “approximately 1 in 4 women in the U.S. obtains an abortion by the age of 45.” (Id., ¶ 21). As authorities for these statistics, Dr. Hopkins cites the National Academy Consensus Study prepared by the National Academy of Sciences, Engineering, and Medicine and reports by the Guttmacher Institute. See National Academy of Sciences, Engineering, and Medicine, The Safety and Quality of Abortion Care in the United States 2018, at 11, 74-75, available at https://doi.org/10.17226/24950) (hereinafter “National Academy Consensus Study Report”); The Guttmacher Institute, Induced Abortion in the United States (January 2011), https://www.guttmacher.org/sites/default/files/factsheet/fbinducedabortion.pdf; The Guttmacher Institute, Abortion is a Common Experience for U.S. Women, Despite Dramatic Declines in Rates (Oct. 2017), https:www.guttmacher.org/news-release/2017/abortion-common-experience-us-women-despite-dramatic-declines-rates. Dr. Hopkins further explains that a “majority of women having abortions in the United States already have one child.” (Id. (citing The Guttmacher Institute, Characteristics of U.S. Abortion Patients in 2014 and Changes Since 2008 (May 2016), https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014)). Testimony consistent with this declaration was offered at the hearing and was subject to cross-examination.

         49. Dr. Hopkins further states that there are two types of abortions in the United States: medication abortion and surgical abortion (Id., ¶ 23).

         50. Dr. Hopkins also states that, regardless of the method of abortion, “serious complications are extremely rare, occurring in less than 0.5% of all cases.” (Decl. of Frederick W. Hopkins, M.D., M.P.H., ¶ 26 (citing Upadhyay, Ushma D., et al., Incidence of Emergency Department Visits and Complications After Abortion, 125 Obstetrics and Gynecology 175 (2015)). The types of complications that may occur following an abortion include infection, prolonged heavy bleeding, uterine perforation, cervical laceration, and retained tissue (Id., ¶ 27). Dr. Hopkins states that in the “vast majority of cases” such complications can be handled in an outpatient office setting (Id.). Testimony consistent with this declaration was offered at the hearing and was subject to cross-examination.

         51. Dr. Hopkins also explains that a woman's risk of pregnancy-related death is estimated to be 8.8 per 100, 000 live births, whereas less than one woman dies for every 100, 000 abortion procedures (Id., ¶ 28 (citing National Academy Consensus Study Report at Table 2-4, 2-24; Zane, S., et al., Obstetrics and Gynecology, Abortion-related mortality in the United States: 1998-2010, at 258-65, available at http://www.ncbi.nlm.nih.gov/pubmed/26241413; Bartlett, L.A., et al., Obstetrics and Gynecology, Risk Factors for legal induced abortion-related mortality in the United States, at 729-37, available at https://www.ncbi.nlm.nih.gov/pubmed/15051566)). Testimony consistent with this declaration was offered at the hearing and was subject to cross-examination.

         52. Additionally, according to Dr. Hopkins, abortion-related mortality is significantly lower than mortality for other common outpatient procedures, including colonoscopies, plastic surgery, dental procedures, or adult tonsillectomies (Decl. of Frederick W. Hopkins, M.D., M.P.H., ¶ 28 (citing National Academy Consensus Study Report, Table 2-4, 2-24)). Testimony consistent with this declaration was offered at the hearing and was subject to cross-examination.

         53. Dr. Hopkins asserts that “no fetus is viable at 18 weeks LMP.” (Id., ¶ 29). Instead, he notes that “[i]t is commonly accepted in the field of OBGYN that a normally developing fetus will not attain viability until at least 24 weeks LMP, ” and he also explains that not all fetuses attain viability even at that stage (Id.).

         54. Dr. Hopkins states that patients can delay abortions for several reasons, including because they do not realize that they are pregnant until later in their pregnancy, difficulty in obtaining funds for the abortion and related expenses, and Arkansas' mandated waiting period (Id., ¶¶ 30-31).

         55. Additionally, Dr. Hopkins explains that some patients seek abortions at or after 18 weeks LMP because they discover a fetal anomaly, some of which cannot be tested for until 18 to 20 weeks LMP (Decl. of Frederick W. Hopkins, M.D., M.P.H., ¶ 32). In other circumstances, the results from prenatal tests performed at 18 to 20 weeks LMP are inconclusive and require referrals to other medical professionals and additional testing, all of which can lead to further delay (Id.). Finally, some women seek abortions at or after 18 weeks LMP because they have a medical condition that does not become apparent until that time or an existing medical condition that worsens during the course of pregnancy (Id., ¶ 33).

         56. Dr. Hopkins further states that, if Act 493 takes effect, he will be forced to stop providing safe and effective pre-viability abortion care that his patients want and need (Id., ¶ 34). He further states that, as a result of Act 493 taking effect, some of his patients will be forced to delay their abortion care, at risk to their health, while they attempt to obtain an abortion out of state (Decl. of Frederick W. Hopkins, M.D., M.P.H., ¶ 34). He also states that others will be prevented from obtaining an abortion altogether and be forced to carry their pregnancies to term against their will, at the expense of their health (Id.).

         57. Dr. Hopkins states that, if the OBGYN requirement goes into effect, Dr. Tvedten, Dr. Horton, and Dr. Ho will be unable to provide abortions (Id., ¶ 35).

         58. In Dr. Hopkins' experience training non-OBGYNs to provide abortions, “there is no difference in the abilities or skills between non-OBGYN practitioners and OBGYNs who have received the necessary training.” (Id., ¶ 36). Dr. Hopkins points out that the OBGYN requirement would allow a physician with no training in abortion to perform abortions while preventing other qualified clinicians with actual training and competency in abortion from providing such care (Decl. of Frederick W. Hopkins, M.D., M.P.H., ¶ 36). Testimony consistent with this declaration was offered at the hearing and was subject to cross-examination.

         59. Dr. Hopkins further states that it is not necessary to be an OBGYN, much less a board-certified or board-eligible OBGYN, to be a competent abortion provider (Id., ¶ 37). According to Dr. Hopkins, the American College of Obstetricians and Gynecologists (“ACOG”), a “highly regarded, reliable, and extensively cited authority in my field, ” recommends expanding the trained pool of non-OBGYN abortion providers, including family physicians and advanced practice physicians (Id. (citing Am. Coll. of Obstetricians and Gynecologists, Committee Op. No. 612 (Nov. 2014), available at https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Abortion-Training-and-Education)). Dr. Hopkins also notes that board-eligibility and board-certification are not required to practice medicine, and he also notes that “[a]t no point in the OBGYN board-eligibility or board-certification process must a physician demonstrate competence in the performance of abortions.” (Id., ¶ 35 n.13). Dr. Hopkins also states that studies recognize that non-OBGYNs are just as qualified and skilled in abortion care as OBGYNs (Decl. of Frederick W. Hopkins, M.D., M.P.H., ¶ 37 (citing National Academy Consensus Study Report, at 11, 14, 79, 95)). Testimony consistent with this declaration was offered at the hearing and was subject to cross-examination.

         60. Dr. Hopkins states that “[a]ny clinician with adequate training in abortion care can safely and effectively handle” the most common abortion complications, even though such complications are rare (Id., ¶ 38). Testimony consistent with this declaration was offered at the hearing and was subject to cross-examination.

         61. In the event a significant complication does arise from an abortion, Dr. Hopkins states that an abortion provider would transfer or direct the patient to the nearest hospital to receive the required care (Id., ¶ 39). If the complication is retained tissue following a medication abortion, Dr. Hopkins states that ACOG Practice Bulletin 143 states that the abortion provider should be trained in surgical abortion “or should be able to refer to a clinician trained in surgical abortion.” (Id. (citing Am. Coll. of Obstetricians and Gynecologists, Practice Bulletin 143 (Mar. 2014), available at https://www.acog.org/-/Practice-Bulletins/Committee-on-Practice-Bulletins----Gynecology/Public/pb143.pdf) (“ACOG Practice Bulletin No. 143”)). Testimony consistent with this declaration was offered at the hearing and was subject to cross-examination.

         62. Dr. Hopkins travels to Arkansas to provide care at LRFP only approximately once every two months (Decl. of Frederick W. Hopkins, M.D., M.P.H., ¶ 42). When he comes to Arkansas, he does so for “three to four days every other month.” (Id., ¶ 44). Since Dr. Hopkins lives in California, each visit to Arkansas requires a day to arrive and to return, so his total duration away from California is five to six days for each visit (Id.). Testimony consistent with this declaration was offered at the hearing and was subject to cross-examination.

         63. Due to Arkansas' 48-hour mandated delay for abortion patients, LRFP treats patients only on Wednesdays, Fridays, and Saturdays, so Dr. Hopkins does not see patients for the entire time he is in Arkansas (Id., ¶ 45). Typically, patients will come in one day for the mandated counseling and two days later for the abortion (Decl. of Frederick W. Hopkins, M.D., M.P.H., ¶ 45). At the hearing, Dr. Hopkins testified that other physicians could perform patient counseling, but he also testified that the counseling is one of the reasons he likes seeing patients and that he does not want to work somewhere where he does not get to provide counseling to patients (Dkt. No. 84, at 47:1-8).

         64. If the 48-hour waiting period is extended to 72-hours, then Dr. Hopkins will attempt to remain in Arkansas for a full five days, versus his regular three to four days (Decl. of Frederick W. Hopkins, M.D., M.P.H., ¶ 47). But, due to his professional obligations in California, he cannot visit Arkansas more frequently than he currently does (Id.). This is because he holds several clinical and teaching positions in California (Id., ¶ 48). He is unable to give up his current positions and relationships with patients who rely upon him in California (Id., ¶ 49).

         65. Additionally, Dr. Hopkins will not relocate to Arkansas because his ability to earn a living in Arkansas would be “extremely uncertain.” (Id., ¶ 50). He predicts that, if he moved to Arkansas, then the Arkansas legislature would pass a new law designed to prevent him from providing abortion care (Decl. of Frederick W. Hopkins, M.D., M.P.H., ¶ 50). Testimony consistent with this declaration was offered at the hearing and was subject to cross-examination. Dr. Hopkins also testified that LRFP has never offered his more money and that, regardless of how much money LRFP might offer him, he could not relocate to Arkansas because that would require him to give up his entire career in California (Dkt. No. 84, at 37:1-10). Dr. Hopkins specifically stated that he would not be willing to relocate to Arkansas and work at LRFP even if they paid him a million dollars (Id., at 37).

         66. Dr. Hopkins also notes that there are usually protestors outside of LRFP (Id., ¶ 51). He is personally familiar with other abortion providers who have been murdered and attacked (Decl. of Frederick W. Hopkins, M.D., M.P.H., ¶ 51). These dangers are “constantly” on Dr. Hopkins' mind when he travels to Arkansas, and this is another reason he cannot move to Arkansas to provide full-time care at LRFP (Id.).

         67. Thomas Russell Horton, Jr., M.D., a staff physician at LRFP and an abortion care provider in Memphis, Tennessee, offers his declaration in support of plaintiffs' motion (Dkt. No. 2-1, at 145-155; Decl. of Thomas Russell Horton, Jr., M.D.). Dr. Horton did not testify at the July 22, 2019, hearing.

         68. Dr. Horton completed his residency in OBGYN, but he is not board-certified or board-eligible in OBGYN (Id., ¶ 5). Dr. Horton will not be able to provide abortion care if the OBGYN requirement goes into effect (Id.).

         69. Dr. Horton began working as a staff physician with LRFP in February 2010 (Id., ¶ 11). Previously, Dr. Horton had provided abortion care in Tennessee up to approximately 15 weeks LMP, so he received training from Dr. Tvedten for performing surgical abortions up to 21.6 weeks LMP (Decl. of Thomas Russell Horton, Jr., M.D., ¶ 11).

         70. As a staff physician for LRFP, Dr. Horton works “one day per week and primarily perform[s] one-day surgical procedures, up to 18 weeks LMP.” (Id., ¶ 12). He also performs multi-day procedures up to 21.6 weeks LMP when he works two or more days per week (Id.).

         71. Dr. Horton has performed thousands of abortions at LRFP “with a very low rate of complications.” (Id., ¶ 13).

         72. Dr. Horton states that becoming a board-certified OBGYN would not make him any more qualified to perform or to handle appropriately the rare complications that may arise following an abortion (Decl. of Thomas Russell Horton, Jr., M.D., ¶ 18). According to Dr. Horton, “training and competence in abortion procedures is not a requirement for either board certification or board eligibility in OBGYN.” (Id.). He also notes that abortion care is not a requirement for completing an OBGYN residency and that many OBGYNs never receive any training for providing abortion care (Id.).

         73. Dr. Horton further explains that, to become a board-certified or board-eligible OBGYN, a physician must first complete his or her residency in OBGYN and then pass a written examination known as the American Board of Obstetrics and Gynecology (“ABOG”) Qualifying Examination (Id., ¶ 19).

         74. After a physician becomes board-eligible, the physician has eight years from the date of completing his or her residency to become board-certified (Decl. of Thomas Russell Horton, Jr., M.D., ¶ 20). If the physician does not become board-certified within those eight years, the physician loses his or her board-eligible status and must complete, at a minimum, an additional six months of supervised practice and assessment in a hospital associated with an accredited OBGYN residency program before he or she may become eligible for certification again (Id.).

         75. Further, to become an ABOG board-certified OBGYN, a physician must: (1) be board-eligible; (2) satisfy certain prerequisites to becoming a candidate for certification, which includes preparing a comprehensive case list and obtaining unrestricted hospital privileges; and (3) sit for and pass another oral examination (Id., ¶ 21).

         76. Dr. Horton completed his residency in OBGYN and passed the written examination for ABOG in June 2002 and June 2013, but he never obtained the necessary case list that is required to be a candidate for board certification (Id., ¶ 22). Dr. Horton states that being a board-certified OBGYN is not relevant or necessary to the provision of abortion care, and he also notes that completing the prerequisites for board-certification would have required him to take significant time away from providing care to his patients (Decl. of Thomas Russell Horton, Jr., M.D., ¶ 22).

         77. Since Dr. Horton did not become board-certified within eight years of completing his residency, he is no longer board-eligible; to retain his board eligibility, he would have to complete a minimum of six months of supervised training (Id., ¶ 23). Dr. Horton states that this is not a feasible option for him because he cannot leave his practice for the required six months to complete the training (Id.). He notes that the required training would provide no medical benefits to his patients (Id.).

         78. Dr. Horton states that, if the OBGYN requirement goes into effect, he will no longer be able to provide abortion care in Arkansas since he is not and cannot become either a board-certified or board-eligible OBGYN (Decl. of Thomas Russell Horton, Jr., M.D., ¶ 24).

         79. Dr. Horton also states that he “regularly” experiences harassment due to his work as an abortion provider (Id., ¶ 26). He notes that every day he has worked at LRFP “there have been protestors and picketers attempting to block the entrance to the parking lot.” (Id.). He further notes that the “protestors often shout at me upon arrival and say things such as: ‘Don't kill those babies, Dr. Horton.'” (Id.).

         80. On June 10, 2009, Dr. Horton was the subject of a bomb threat at the Memphis Center for Reproductive Health (“MCRH”) in Memphis, Tennessee (Decl. of Thomas Russell Horton, Jr., M.D., ¶ 27). An individual called MCRH and informed the clinic staff that there was a bomb in Dr. Horton's car (Id.). The clinic staff were forced to evacuate the clinic (Id.).

         81. Dr. Horton's ability to maintain or find a job in private practice have been directly affected by his work as an abortion provider (Id., ¶ 28). Around 2004 and 2005 in Memphis, Dr. Horton applied to several jobs as a generalist in private practice, but he did not receive any job offers and was not able to find other work due to his work as an abortion provider (Decl. of Thomas Russell Horton, Jr., M.D., ¶ 28). In 2005, Dr. Horton was in the final round of interviews for a position in private practice in Richmond, Virginia, when he asked the prospective employer if he would be allowed to continue providing abortion care in Memphis while working in private practice; he did not receive a job offer and never heard from that prospective employer again (Id.). In 2005, while working at the Baptist Memorial Hospital-Crittenden in Arkansas, he was approached by one of the labor-and-delivery nurses at the hospital regarding abortion care (Id.). Afterward, he was informed that his services were no longer needed at that hospital (Id.). He later found out that a different OBGYN resident filled the position Dr. Horton had occupied at that hospital (Decl. of Thomas Russell Horton, Jr., M.D., ¶ 28).

         82. Many of Dr. Horton's patients at LRFP are low-income and have a difficult time paying for an abortion (Id., ¶ 30). His patients may have to borrow money from a friend or a family member for the abortion or to rent a car or pay for a hotel in Little Rock (Id.). His patients often delay their care while they raise the necessary funds and make logistical arrangements (Id.).

         83. Patients who are poor or low-income usually have jobs in which they do not get vacation or sick time, and it is difficult for such patients to take even a half day off work to be seen at LRFP (Id., ¶ 31). Dr. Horton states that, if such patients must take significant time off to travel out of state for a surgical abortion, they may lose their jobs (Decl. of Thomas Russell Horton, Jr., M.D., ¶ 31). Additionally, patients often have difficulty obtaining child care; Dr. Horton states that on several occasions, patients have brought young children with them to their appointments at LRFP (Id., ¶ 32). He also states that, for women who do not want to or cannot bring their children with them to their appointments, finding child care for a whole day or more to travel out of state would be extremely difficult, if not impossible (Id.).

         84. Dr. Horton states that, if the OBGYN requirement goes into effect, then those patients who cannot obtain sufficient funds to travel out of state will be forced to either attempt to self-induce an abortion or carry their pregnancies to term against their will (Id., ¶ 33).

         85. Sheila M. Katz, Ph.D., offers her declaration in support of plaintiffs' motion (Dkt. No. 2-1, at 162-189; Decl. of Sheila M. Katz, Ph.D.). Dr. Katz is an assistant professor of sociology at the University of Houston, in Houston, Texas (Id., ¶ 9). Her research has included qualitative methods and data analysis regarding women's experiences of poverty, and her expertise includes the consequences and social policy determinants of women's poverty nationwide, as well as regional and geographical similarities and differences across the United States (Id.).

         86. The United States Department of Health and Human Services defines the federal poverty guideline as an income of under $12, 490.00 per year for a single person, with $4, 420.00 added per year for each additional member of the household (Id., ¶ 12).

         87. According to 2017 Census Bureau data, Arkansas is the fifth poorest state in the United States, and its official poverty rate was 18.1% statewide (Decl. of Sheila M. Katz, Ph.D., ¶ 14). The poverty rate for women in Arkansas is even higher, at 19.5% (Id.).

         88. The federal poverty guideline, while widely used, is considered by some to be an inadequate measure of poverty in the United States (Id., ¶ 17). Thus, in addition to those who fall below the federal poverty line, most poverty researchers consider individuals and family between 100% and 200% of the federal poverty line to be “low-income.” (Id., ¶ 18).

         89. In Arkansas, 46.8% of families headed by single mothers with dependent children are living at or below 125% of the federal poverty line, and 37.5% are living at less than 100% of the federal poverty line (Decl. of Sheila M. Katz, Ph.D., ¶ 19).

         90. Further, many poor individuals are part of the “working poor, ” which Dr. Katz defines as those working at minimum wage or earning so little that they cannot meet basic needs for themselves or their family (Id., ¶ 20). The Bureau of Labor Statistics defines the “working poor [as] people who spent at least 27 weeks in the labor force . . . but whose incomes still fell below the official poverty level.” (Id.).

         91. According to Dr. Katz, a woman working full-time (40 hours a week) earning minimum wage in Arkansas now has annual earnings of approximately $19, 240.00, which is just above the federal poverty threshold if she has one child in her household and below the poverty line if she has more children (Id., ¶ 21).

         92. Dr. Katz states that the fair market rent, as designated by the United States Department of Housing and Urban Development, is $702.00 for a one-bedroom apartment and $831.00 for a two-bedroom apartment in Little Rock, Arkansas (Decl. of Sheila M. Katz, Ph.D., ¶ 22). If a woman in Little Rock has a full-time job earning the minimum wage, she would pay approximately 44% of her monthly income for a one-bedroom apartment and approximately 52% of her monthly income for a two-bedroom apartment (Id.).

         93. In Arkansas, 17.6% of families headed by single mothers are living in “deep poverty, ” which Dr. Katz characterizes as a household that lives at or below 50% of the federal poverty line (Id., ¶ 24).

         94. In addition, 17 counties in Arkansas suffer from “persistent poverty, ” which Dr. Katz defines as a county where the poverty rate has been at or above 20% for the past 30 years (Id., ¶ 25).

         95. Dr. Katz explains that Arkansas women living in deep or persistent poverty face the greatest logistical, financial, and psychological hurdles to accessing health care services since they are the least likely to have adequate transportation, childcare, and financial resources and support (Decl. of Sheila M. Katz, Ph.D., ¶ 26).

         96. Over two-thirds of women who obtain abortions in Arkansas already have at least one child (Id., ¶ 27).

         97. Dr. Katz states that it is her understanding that women in and around Little Rock who can now obtain both medication and surgical abortion through 21.6 weeks LMP at LRFP may be forced to travel out of state to obtain that care from the next closest provider (Id., ¶ 28). She states that the next-closest abortion provider is in Memphis, Tennessee, which is an approximately 300-mile round trip journey from Little Rock (Id.). Dr. Katz also states that such a journey would have to be made twice, as Tennessee requires “multiple, in person visits to the abortion clinic separated by at least 48 hours before a woman can obtain an abortion (Decl. of Sheila M. Katz, Ph.D., ¶ 28).

         98. Dr. Katz is familiar with the research analyzing the effect of increased travel on women's ability to obtain abortions, and she states that this research shows that increasing the distance that women must travel to access abortion services presents significant logistical and financial hurdles (Id., ¶ 30).

         99. Dr. Katz states that for those women who do not own or have access to vehicles, the only significant intercity transportation between Little Rock and Memphis-other than flying-is a private bus service, such as Greyhound (Id., ¶ 34). A single round-trip Greyhound bus ticket between Little Rock and Memphis costs between $24.00 and $85.00 (Id.). If a woman must bring someone to accompany her in the event a sedative is used, this cost doubles (Decl. of Sheila M. Katz, Ph.D., ¶ 34). Further, a woman traveling by private bus may have to pay for the cost of taxi or bus fares to and from the private bus station in both Little Rock and Memphis (Id.). Moreover, given Tennessee's 48-hour waiting requirement, either two bus trips would be required, or the woman would have to pay for two nights hotel accommodations in Memphis, which Dr. Katz says cost anywhere from $50.00 to $75.00 per night (Id.).

         100. Dr. Katz also points out that many poor and low-income women in Arkansas “likely do not own or have access to cars that are reliable enough to make a trip of the length required.” (Id., ¶ 36). Dr. Katz notes that, even if a low-income woman owns a car, it may be shared among adults, and it may not be reliable enough for intercity trips (Decl. of Sheila M. Katz, Ph.D., ¶ 36). Dr. Katz also points out that the cost of gas for round-trip car travel from Little Rock to Memphis is approximately $23.00 (Id., ¶ 37).

         101. Dr. Katz explains that low-wage workers often have no access to paid time off or sick days and that seeking uncompensated time off can be a struggle for low-wage workers who often have less autonomy in setting their work schedules (Id., ¶ 39). Further, low-wage workers often work unpredictable, varied, or evening jobs (Id.). Dr. Katz states that the additional time off required by travel may make it difficult for a poor or low-income woman to keep her abortion confidential from her supervisor or other employees (Decl. of Sheila M. Katz, Ph.D., ¶ 39).

         102. Also, Dr. Katz points out that intercity travel for an abortion requires a woman to miss work (Id., ¶ 40). In the event a woman can get time off, she is likely to forego wages in addition to paying for transportation and lodging (Id.). At the minimum wage in Arkansas of $9.25, foregoing two eight-hour shifts to travel to and attend abortion counseling and procedure appointments would result in $148.00 in lost wages, which is almost 10% of a woman's monthly income if she works a full-time minimum wage job (Id.). These lost wages are on top of the cost of the abortion and other logistical costs (Decl. of Sheila M. Katz, Ph.D., ¶ 40).

         103. Dr. Katz points out that, for those two-thirds of women seeking an abortion who already have a child, they must either pay the cost of an additional round-trip bus ticket for her child or pay the cost of childcare for the entire time she is traveling (Id., ¶ 41 (citing Tara C. Jatlaoui et al., Ctrs. for Disease Control and Prevention, Abortion Surveillance-United States 2015, 67 MMWR Surveill. Summ. 1, at Table 16 (2018)). Alternatively the woman may be able to leave her child with a trusted family member or friend, though this may require that the woman disclose why she is traveling (Id.).

         104. In sum, according to Dr. Katz, the total additional financial burden that a woman in or around Little Rock would have to incur to obtain a surgical abortion if she were forced to travel to Memphis would amount up to approximately $468.00, including lost wages, but not including childcare, food, or the cost of the procedure itself (Id., ¶ 44). For a woman working full-time and making Arkansas minimum wage, this is over a quarter of her monthly salary of $1, 603.00 (Decl. of Sheila M. Katz, Ph.D., ¶ 44).

         105. Dr. Katz also points out that a low-income woman may never have traveled outside the metropolitan or rural area where she lives, so even if she is able to gather the money necessary to make the trip, “the social-psychological hurdles of making multiple trips to an unfamiliar city, where she may know no one, may impede her.” (Id., ¶ 47). Accordingly to Dr. Katz, many of the women she has spoken to in her research indicate that, if a service is not available in their town or within a reasonable distance, “that service might as well not exist.” (Id.).

         106. Dr. Katz points out that poor and low-income women attempt to meet unexpected expenses in three ways: (1) by making sacrifices in other areas, such as by not paying rent or utilities, drastically reducing food budgets, or foregoing needed medical care; (2) by borrowing money through payday loans; and (3) by borrowing money from a boyfriend or partner (Id., ¶¶ 50-52). Dr. Katz explains that in her own interviews with poor and low-income women, such women talk about the economic necessity of relying on or returning to an abusive ex-boyfriend to help make ends meet when faced with an unexpected crisis (Decl. of Sheila M. Katz, Ph.D., ¶ 52).

         107. Dr. Katz is also familiar with studies analyzing the effect of increased travel on women's ability to obtain abortions (Id., ¶ 54). The “Turnaway Study” found that the most common reason women were delayed in accessing abortion care was because of travel and procedure costs (Id., ¶ 55 (citing Upadhyay, Ushma D., et al., Denial of abortion because of provider gestational age limits in the United States, 104.9 Am. J. of Pub. Health 1687, 1697-94 (2014)). Furthermore, that study also cited that women reported that they experienced delay as a result of having to get time off work, finding child care, and not having anyone to travel with them (Id.).

         108. Another study found that the most common reason for delay was that it took a long time to make abortion care arrangements and that poverty made women twice as likely to be delayed in making the arrangements to seek an abortion (Decl. of Sheila M. Katz, Ph.D., ¶ 56).

         109. In the “Shelton Study, ” researchers concluded that “the farther a woman has to travel to obtain an abortion, the less likely she is to obtain one.” (Id., ¶ 57). Furthermore, a recent study of Texas women seeking an abortion after the implementation of a law restricting abortion access documented that women were worried that they would suffer stigma if they utilized their social networks to overcome the barriers of traveling long distances to obtain abortion care (Id., ¶ 58).

         110. Jason Lindo, Ph.D., a professor of economics at Texas A&M University, presents his declaration in support of plaintiffs' motion (Dkt. No. 2-1, at 200-237; Decl. of Jason Lindo, Ph.D.). He has been a research associate at the National Bureau of Economic Research (“NBER”) since 2014 (Id., ¶ 5). Dr. Lindo testified at the July 22, 2019, hearing.

         111. It is Dr. Lindo's understanding that there are three types of abortions currently provided in Arkansas: (1) medication abortions that are available only up to 10 weeks LMP; (2)

         aspiration surgical procedures that are available until approximately 13 weeks LMP; and (3) dilation and evacuation (“D&E”) surgical procedures, which are performed until 21.6 weeks LMP (Id., ¶ 11).

         112. Dr. Lindo explains that it is his understanding that medication abortions in Arkansas require three trips and that, under a new law set to take effect on July 24, 2019, the mandated delay between the first and second visits will increase to 72 hours (Id., ¶ 12).

         113. As for surgical abortions, Dr. Lindo explains that two trips are required, though a third visit may be necessary for some D&E procedures performed later in the second trimester (Decl. of Jason Lindo, Ph.D., ¶ 13).

         114. Dr. Lindo notes that LRFP is owned and operated by Dr. Tvedten, who provides approximately 61% of the abortion care at LRFP (Id., ¶ 14(a)). Dr. Horton provides approximately 33% of the clinic's abortion care, and the remaining six percent of the clinic's abortion care has been provided by Dr. Hopkins (Id.). Neither Dr. Tvedten nor Dr. Horton are board-certified or board-eligible OBGYNs (Id.).

         115. Dr. Rodgers and Dr. Cathey provide medication abortions at PPAEO's Little Rock health center (Decl. of Jason Lindo, Ph.D., ¶ 14(b)). Through April 2019, Dr. Cathey has provided 229 medication abortions while Dr. Rodgers has provided 199 medication abortions in the same time (Id.).

         116. Between May 1, 2016, and April 30, 2019, LRFP provided 7, 010 abortions, including 6, 128 (or 87%) to Arkansas residents, 483 (or 7%) to Tennessee residents, and 188 (or 2.7%) to Mississippi residents (Decl. of Jason Lindo, Ph.D., ¶ 15).

         117. Between 2016 and 2019, approximately 75.5% of LRFP's procedures were aspiration abortions (5, 291); approximately 19.2% were D&E abortions (1, 346), and approximately 5.3% were medication abortions (376) (Id., ¶ 16).[3]

         118. Dr. Lindo analyzed several academic studies published in peer-reviewed journals that have documented that abortion regulations can have impacts on women's ability to access abortion care (Id., ¶ 21). While there are some differences across these studies in terms of the data that were used and the set of outcomes that were evaluated, all three determined that increases in distance to the nearest clinic caused by regulation-induced clinic closures caused significant reductions in abortions obtained from medical professionals (Id., ¶ 24).

         119. Dr. Lindo also evaluated the effects in Arkansas when the contracted physician requirement eliminated the availability of medication abortion in Arkansas from May 31 through June 18, 2018 (Decl. of Jason Lindo, Ph.D., ¶ 32). Dr. Lindo concludes that the contracted physician requirement reduced the number of abortions obtained from Arkansas providers by Arkansas residents by 17-27% (Id., ¶ 35).

         120. Dr. Lindo also projects that Dr. Hopkins will likely be able to serve 42 women every other month, an estimate based upon the fact that Dr. Hopkins has served, at most, 21 women in any given day in the last three years (Id., ¶ 49(c)).

         121. Dr. Lindo projects that Dr. Paulson will be able to provide abortions to a maximum of 12 patients per week (Id.).

         122. Based upon his past capacity to provide abortions, Dr. Lindo estimates that Dr. Rodgers will be able to provide 480 medication abortions annually (Decl. of Jason Lindo, Ph.D., ¶ 50 (Table 8)). Furthermore, taking into account that Dr. Cathey intends to add a half day to her provision of abortion care, Dr. Lindo estimates that she will be able to provide 476 medication abortions annually (Id.). Testimony consistent with this declaration was offered at the hearing and was subject to cross-examination.

         123. Dr. Lindo has examined the likely effects of the OBGYN requirement on Arkansas women's ability to access abortion care (Id., ¶ 41). To do so, Dr. Lindo presents his supplemental declaration (Dkt. No. 37; Supp. Decl. of Jason Lindo, Ph.D.).

         124. Dr. Lindo points out that he has learned that, during the week of July 1, 2019, PPAEO stopped providing medication abortions at its Fayetteville health center (Id., ¶ 2). Accordingly, he has evaluated the likely effects of the OBGYN requirement under the current changed circumstances where PPAEO Little Rock and LRFP are the only providers of abortion care in Arkansas (Id.).

         125. Dr. Lindo evaluates the effects of the OBGYN requirement under these changed circumstances in three different scenarios: (1) no OBGYN requirement; (2) the OBGYN requirement goes into effect and LRFP is forced to close; and (3) the OBGYN requirement goes into effect and LRFP stays open, allowing Dr. Hopkins to provide abortions every other month (Id., ¶ 3).

         126. In order to ensure that he does not conflate the effects of PPAEO Fayetteville not offering abortions with the effects of the OBGYN requirement, Dr. Lindo's supplemental declaration focuses upon women who have historically been served by LRFP and PPAEO Little Rock (Supp. Decl. of Jason Lindo, Ph.D., ¶ 8). In particular, his supplemental declaration focuses “on the 2, 614 women annually served at these two locations over the past three years.” (Id.). Thus, according to Dr. Lindo, he is providing a conservative estimate of the effect of the OBGYN requirement since more than 2, 614 women are likely to seek abortions in Little Rock annually, given that medication abortions are no longer available at PPAEO Fayetteville (Id.).

         127. Dr. Lindo also explains that, based upon an average from 2016 to 2019, 2, 779 Arkansas residents obtain an abortion each year (Decl. of Jason Lindo, Ph.D., ¶ 51). Dr. Lindo's declaration also states that, based upon a three-year average, 1, 927 Arkansas women seek surgical abortions in Arkansas annually (Id., ¶ 61).[4]

         128. Dr. Lindo concludes that, of the 2, 212 women who annually obtain surgical abortions in Arkansas, none of them will be able to do so if the OBGYN requirement goes into effect and LRFP is forced to close (Supp. Decl. of Jason Lindo, Ph.D., ¶ 10). Put another way, of the 2, 614 women who obtain abortions in Little Rock annually, 2, 212 (or 85%) of those women will not be able to obtain the same type of care in Arkansas that they otherwise would, absent the OBGYN requirement (Id., ¶ 10).

         129. Dr. Lindo also performed calculations that assume that some women who would have received surgical abortions will substitute for medication abortions. Dr. Lindo estimates that LRFP and PPAEO Little Rock currently have the capacity to provide up to 4, 664 abortions annually and that, if the OBGYN requirement goes into effect and LRFP is forced to close, that number will fall to 956, [5] which is the sum of Dr. Rodgers and Dr. Cathey's total estimated capacity (Id., ¶ 11). Accordingly, 1, 658 (or 63%) of the 2, 614 women who otherwise would obtain abortion care in Little Rock annually will not be able to access any type of abortion care in Arkansas if the OBGYN requirement goes into effect and LRFP closes (Id.). And 1, 658 (or 52%) of the 3, 167 women who have historically obtained abortion care in Arkansas annually (including at PPAEO Fayetteville) will not be able to access any type of abortion care in Arkansas (Supp. Decl. of Jason Lindo, Ph.D., ¶ 11).

         130. Dr. Lindo also projects that, if the OBGYN requirement goes into effect and LRFP does not close, the availability of surgical abortions at LRFP will increase from 0 to 252 compared to the scenario where LRFP closes (Id., ¶ 12). Accordingly, in this scenario, all but 252 of the women who would otherwise seek surgical abortions would have no provider in Arkansas (Id., ¶ 13). Typically, 2, 212 women have obtained surgical abortions each year in Little Rock (Id., ¶ 12). Testimony consistent with this declaration was offered at the hearing and was subject to cross examination.

         131. As such, according to Dr. Lindo, 1, 960 (or 75%) of the 2, 614 women who obtain abortions in Little Rock annually will not be able to obtain the same type of care in Arkansas that they would otherwise seek, absent the OBGYN requirement (Supp. Decl. of Jason Lindo, Ph.D., ¶ 13). Additionally, these 1, 960 are 62% of the 3, 167 women who would historically have obtained abortion care in Arkansas annually (including PPAEO Fayetteville) but who will not be able to obtain the same type of care in Arkansas that they would have, absent the OBGYN requirement (Id.).

         132. Dr. Lindo does account for the possibility that PPAEO Little Rock could provide up to 956 medication abortions annually for women who would historically have obtained abortion care in Arkansas. In conjunction with the 252 surgical abortions that LRFP could provide it if remains open despite the OBGYN requirement, this means that 1, 406 (or 54%) of the 2, 614 women who otherwise would obtain care in Little Rock annually will not be able to access any type of abortion care in Arkansas (Id., ¶ 14). Furthermore, 1, 406 (or 44%) of the 3, 167 women who have historically obtained abortion care in Arkansas annually (including at PPAEO Fayetteville) will not be able to obtain any type of abortion care in Arkansas (Id.).

         133. Upon cross examination, Dr. Lindo testified that his conclusions were based upon information provided to him by plaintiffs and that, depending upon the assumptions made, his conclusions could change (Dkt. No. 84, at 144:14-16). Dr. Lindo also noted during his testimony that the capacity to provide abortions in his calculations are determined by the physicians who can provide abortion care (Id., at 150:1-4).

         134. Kathleen Paulson, M.D., a board-certified OBGYN licensed to practice medicine in Arkansas, offers her declaration in support of plaintiffs' motion (Dkt. No. 2-1, at 248-250; Decl. of Kathleen Paulson, M.D.). Dr. Paulson provides medical services, including outpatient gynecologic care and women's wellness care, at a medical center in Fayetteville, Arkansas (Id., ¶ 1).

         135. Linda W. Prine, M.D., a board-certified family physician, offers her declaration in support of plaintiffs' motion (Dkt. No. 2-1, at 252-261; Decl. of Linda W. Prine, M.D.). Dr. Prine is a professor of family medicine and community health at the Icahn School of Medicine at Mount Sinai, and she also holds teaching positions at the Harlem Family Medicine Residency Program and the Mount Sinai Downtown Residency in Urban Family Medicine (Id., ¶ 4). She also maintains an active medical practice, including as a clinician at Planned Parenthood of New York City (Id.). Dr. Prine has provided medication and surgical abortion care to women up to sixteen weeks LMP, and over the last eighteen years, she has trained thousands of clinicians to provide abortion care (Id., ¶ 5). She states that those clinicians have come from several specialties, including family medicine, pediatrics, OBGYN, and internal medicine (Decl. of Linda W. Prine, M.D., ¶ 5). Dr. Prine testified at the July 22, 2019, hearing.

         136. Dr. Prine knows of numerous family medicine practitioners who provide abortion care up to 24 weeks or more LMP (Id., ¶ 7). Furthermore, she has trained advanced practice clinicians, such as nurse practitioners, to provide abortion care (Id., ¶ 8). She states that it is well established that advanced practice clinicians can provide surgical abortion as safely and effectively as physicians (Id.). Testimony consistent with this declaration was provided at the hearing and was subject to cross examination (Dkt. No. 84, at 51:8-12).

         137. Dr. Prine explains that the scope of practice for family medicine practitioners is significantly more complex than abortion care; specifically, she notes that managing a patient's diabetes, heart disease, hypertension, and/or HIV/AIDS, or performing any number of other minor outpatient surgical procedures is more complex than abortion care (Decl. of Linda W. Prine, M.D., ¶ 16). She further notes that family practitioners provide miscarriage management, prenatal care, and delivery to low-risk patients (Id.). Dr. Prine states that miscarriage management involves many of the same skills required for abortion providers and that delivery, even to low-risk patients, has a higher complication rate than providing abortions (Id., ¶ 17 (citing Raymond & Grimes, supra, at 216-17)).

         138. In Dr. Prine's experience, residents from all specialties can become qualified abortion providers (Id., ¶ 20). According to Dr. Prine, one third of abortion providers in this country come from specialties other than OBGYN and that, based upon her experience, there is no difference in the training of an OBGYN resident and other clinicians in these skills (Decl. of Linda W. Prine, M.D., ¶ 20 (citing Katharine O'Connell, et al., First-Trimester Surgical Abortion Practices: A Survey of National Abortion Federation Members, 79 Contraception 385 (2009); Katharine O'Connell, et al., Second-Trimester Surgical Abortion Practices: A Survey of National Abortion Federation Members, 78 Contraception 492 (2008))).

         139. Dr. Prine points out that ACOG characterizes requirements “that clinic physicians be board certified obstetricians-gynecologists despite the fact that clinicians in many medical specialties can provide safe abortion services” as “medically unnecessary requirements designed to reduce access to abortion.” (Id., ¶ 21 (citing Am. Coll. of Obstetricians and Gynecologists, Committee Op. No. 613 (Nov. 2014), https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-onhealth-Care-for-Underserved-Women/Increasing-Access-to-Abortion)). Additionally, the American Academy of Family Physicians (“AAFP”) adopted in 2014 a resolution opposing laws that “impose[] on abortion providers unnecessary requirements that infringe on the practice of evidence-based medicine.” (Id., ¶ 22 (citing Am. Acad. of Family Physicians, Resolution No. 10001, Oppose Targeted Regulation Against Abortion Providers (TRAAP laws) (2014), http://www.aafp.org/about/constit uencies/past-ncsc/2014.html)). Dr. Prine opines that the OBGYN requirement is the type of unnecessary requirement to which the AAFP policy refer, as it restricts access to abortion care with no medical benefit to patients (Id.). Dr. Prine also points out that the American Public Health Association likewise recognizes that training, not specialty, determines competence in providing abortion care (Id., ¶ 24 (citing Am. Public Health Ass'n, Policy Statement: Provision of Abortion Car by Advanced Practice Nurses and Physician Assistants, https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/28/16/00/provision-of-abortion-care-by-advanced-practice-nurses-and-physician-assistants)).

         140. Dr. Prine cites a comprehensive report by the National Academies of Sciences, Engineering, and Medicine that states that family medicine physicians, among other clinicians, can “safely and effectively” provide medication and surgical abortions (Decl. of Linda W. Prine, M.D., ¶ 26 (citing National Academy Consensus Study Report, at 14)). This report concluded medication and suction aspiration abortions performed by family medicine physicians had high success rates and that “[a]ll complications were minor and managed effectively at rates similar to those in OB/GYN practices and specialty abortion clinics.” (Id., ¶ 27 (citing National Academy Consensus Study Report, at 105)). The report further concluded that “OB/GYNs, family medicine physicians, and other physicians with appropriate training and experience can provide D&E abortions.” (Id. (citing National Academy Consensus Study Report, at 14)).

         141. Dr. Prine concludes that restricting the provision of abortion care to board-certified or board-eligible OBGYNs is not medically justified and provides no medical benefit (Id., ¶ 29). At the hearing, Dr. Prine testified that the National Academy Consensus Study Report confirmed that competencies do not depend on board certification but rather on the training and experience of the individual physician (Dkt. No. 84, at 62:8-12).

         142. Dr. Prine also submits a supplemental declaration in support of plaintiffs' motion (Dkt. No. 62-1; Supp. Decl. of Linda W. Prine, M.D.). Dr. Prine “strongly disagree[s]” with any contention that abortion creates or causes psychological or emotional problems that do not already exist or would have arisen regardless of the procedure (Id., ¶¶ 2-3). Citing reports from the National Academies of Sciences, Engineering and Medicine, the American Psychological Association (“APA”) Task Force on Mental Health and Abortion, and the Academy of Medical Royal Colleges, Dr. Prine states that “the rates of mental health problems for women with an unwanted pregnancy are the same whether they have an abortion or give birth” and that “there is no evidence that abortion gives rise to serious psychological and emotional harms.” (Id., ¶ 5 (citing Am. Psychological Ass'n, Task Force on Mental Health and Abortion, Report of the Task Force on Mental Health and Abortion, at 7-8 (2008), available at http://www.apa.org/pi/wpo/mental-health-abortion-report.pdf)).

         143. Alison Stuebe, M.D., M.Sc., Fellow of the American College of Obstetrics and Gynecology (“F.A.C.O.G.”), provides her declaration in support of plaintiffs' motion (Dkt. No. 2-1, at 290-301; Decl. of Alison Stuebe, M.D., M.Sc. F.A.C.O.G.). Dr. Stuebe is a board-certified maternal-fetal medicine specialist (“MFM”) and OBGYN (Id., ¶ 1). As an MFM, Dr. Stuebe specializes in the management of high-risk pregnancies; MFMs obtain three additional years of fellowship training, beyond the standard residency period for an OBGYN (Id.).

         144. Dr. Stuebe is an associate professor in the Department of Obstetrics and Gynecology and the Department of Maternal and Child Health at the University of North Carolina (“UNC”) School of Medicine (Id., ¶ 3). She also serves as the Associate Director for Research and Development at the UNC Center for Maternal and Infant Health (Decl. of Alison Stuebe, M.D., M.Sc. F.A.C.O.G., ¶ 3). Since 2008, Dr. Stuebe has trained hundreds of medical students, residents, and fellows in OBGYN (Id.).

         145. Dr. Stuebe also maintains an active clinic practice focusing on care for women with high-risk pregnancies (Id., ¶ 5). A substantial part of her clinical work consists of conducting ultrasound and prenatal diagnostic tests and counseling women about fetal abnormalities (Id.).

         146. Since UNC is a state hospital, Dr. Stuebe cares for patients from a wide range of socioeconomic and cultural backgrounds, including women who are undocumented immigrants without health insurance and women who are UNC employees with private insurance (Decl. of Alison Stuebe, M.D., M.Sc. F.A.C.O.G., ¶ 6).

         147. While Dr. Stuebe currently does not provide medication or surgical abortions as part of her clinical practice, she does currently assist women in terminating pregnancies involving fetal anomalies through medical induction of labor at the hospital (Id., ¶ 7).

         148. In her MFM practice, Dr. Stuebe regularly treats and counsels with pregnant women about genetic and other fetal anomalies (Id., ¶ 12). Because of her education, training, and clinic work, Dr. Stuebe is very familiar with the genetic anomaly Trisomy 21, which is commonly referred to as Down syndrome (Id., ¶¶ 12-13). While there are various risk factors for Down syndrome, Dr. Stuebe states that there is no way to predict before pregnancy whether a woman will have a fetus with Down syndrome (Decl. of Alison Stuebe, M.D., M.Sc. F.A.C.O.G., ¶ 14).

         149. Dr. Stuebe explains that there are a number of screening and diagnostic tests available to determine the presence of certain genetic, chromosomal, and structural anomalies, including Down syndrome (Id., ¶ 17). Screening tests cannot diagnose any anomaly and only indicate a likelihood or probability that one or more anomalies exist (Id., ¶ 18). Screening tests usually screen for a range of anomalies at the same time and may indicate a likelihood of more than one anomaly at once (Id.). Diagnostic tests, on the other hand, determine the existence or non-existence of anomalies with near certainty (Decl. of Alison Stuebe, M.D., M.Sc. F.A.C.O.G., ¶ 18).

         150. There are multiple Down syndrome screening tests used during pregnancy: the fetal cell-free DNA test; nuchal translucency and serum-marker screening tests; maternal serum quadruple marker (“Quad Screening”) tests; and targeted ultrasound examination (Id., ¶ 22).

         151. Cell-free DNA testing can be performed as early as 10-12 weeks LMP, and results are usually available within 7 days (Id., ¶ 22(a)). Cell-free DNA tests detect approximately 99% of pregnancies affected with Down syndrome, though false positive results are higher for low-risk women (Id.). ACOG, therefore, advises that women should not take irreversible action based upon a cell-free DNA test result alone (Decl. of Alison Stuebe, M.D., M.Sc. F.A.C.O.G., ¶ 22(a) (citing ACOG Practice Bulletin No. 163)).

         152. If a screening test indicates an increased probability of a fetal genetic condition or aneuploidy, Dr. Stuebe offers a diagnostic test to confirm whether the genetic condition indicated by the screening test is present (Id., ¶ 23). There are two techniques for obtaining fetal cells for diagnostic testing: chorionic villus sampling (“CVS”) and amniocentesis (Id., ¶ 24).

         153. Dr. Stuebe states that most women do not receive a confirmed diagnosis of Down syndrome until well into the second trimester of pregnancy (Id., ¶ 25). Further, amniocentesis is more widely available than CVS and cannot be performed until 15 weeks LMP, and test results from amniocentesis are often unavailable until 17 weeks LMP (Decl. of Alison Stuebe, M.D., M.Sc. F.A.C.O.G., ¶ 25). Furthermore, a clinician performing an ultrasound may not be able to detect any associated anatomical abnormalities before approximately 18 weeks LMP (Id.).

         154. Dr. Stuebe states that Act 619 will encourage women to withhold screening and diagnostic test results from medical providers the women visit for care, which could have negative consequences for both the clinician-patient relationship and women's health, especially since understanding the meaning and reliability of various screening and diagnostic tests can be difficult (Id., ¶ 29).

         155. Additionally, Dr. Stuebe states that Act 493 will “make it extremely difficult, if not impossible, for women to take the time necessary to confirm a diagnosis of Down syndrome or another fetal anomaly, and make an informed, autonomous decision regarding whether to carry to term or terminate the pregnancy.” (Id., ¶ 30). Specifically, amniocentesis results are unavailable before 16-17 weeks LMP, and targeted ultrasound examinations cannot be performed reliably until approximately 18 weeks LMP, at the earliest (Decl. of Alison Stuebe, M.D., M.Sc. F.A.C.O.G., ¶ 30). Dr. Stuebe states that Act 493 creates artificial time pressure that could lead women and their families to rush their decision-making process for no medically justified reason (Id.).

         156. Thomas Tvedten, M.D., the part owner and Medical Director of LRFP, provides his declaration in support of plaintiffs' motion (Dkt. No. 2-1, at 371-384; Decl. of Thomas Tvedten, M.D.). Dr. Tvedten testified at the July 22, 2019, hearing.

         157. Dr. Tvedten first began training to provide abortion care in 1985 at Women's Community Health in Little Rock, a clinic that used to provide abortion care in Arkansas (Id., ¶ 5). Dr. Tvedten was trained by an experienced abortion provider and family medicine physician who had been providing abortion care in Arkansas since the 1970s (Id.). Dr. Tvedten began by first learning, and then providing, first trimester abortion care (Id., ¶ 6). After speaking to other providers and observing them perform second trimester procedures, Dr. Tvedten expanded the scope of his practice to second trimester procedures, eventually performing procedures up to approximately 21 weeks, 6 days LMP (Decl. of Thomas Tvedten, M.D., ¶ 7). Dr. Tvedten has consistently provided abortion care up to 21.6 weeks LMP for more than 15 years (Id.).

         158. Starting in 2004, after the Federal Drug Administration (“FDA”) approved Mifeprex for combined use with misoprostol for early non-surgical abortion, Dr. Tvedten began providing medication abortion up to 10 weeks LMP (Id., ¶ 8).

         159. Dr. Tvedten has also trained numerous providers to provide both medication and surgical abortions (Id., ¶ 9). Family planning and OBGYN residents and medical students regularly come to LRFP to observe Dr. Tvedten performing abortion procedures and to receive training (Decl. of Thomas Tvedten, M.D., ¶ 9). Furthermore, many OBGYNs in Arkansas refer patients to Dr. Tvedten for abortion care that they are not trained to or are unable to provide (Id., ¶ 10).

         160. Dr. Tvedten states that, while complications arising from either medication or surgical abortion are extremely rare, he is trained to handle effectively and safely any issue that may arise, either by providing the follow-up care himself or by referring his patients to a “tertiary care facility.” (Id., ¶ 11).

         161. Dr. Tvedten takes steps to ensure that he is always up to date on the latest advances in abortion care (Id., ¶ 12). For example, he attends yearly conferences on abortion care to further his education (Decl. of Thomas Tvedten, M.D., ¶ 12). He also discusses abortion care and complex abortion cases with other providers, including his OBGYN colleagues, and he reads practice bulletins issued by medical authorities such as ACOG (Id.). He also reviews articles published in peer-reviewed medical journals, such as Obstetrics & Gynecology, Contraception, the Journal of the American Medical Association, and other sources on this topic (Id.).

         162. At LRFP, Dr. Tvedten and two other physicians provide surgical abortions up to 21.6 weeks LMP and medication abortions up to 10 weeks LMP (Id., ¶ 15). LRFP is one of three abortion clinics in Arkansas and is the only one that offers surgical abortions (Decl. of Thomas Tvedten, M.D., ¶ 15). Accordingly, LRFP is the only option for women seeking abortion care after 10 weeks LMP in Arkansas (Id.).

         163. Dr. Tvedten points out that Arkansas law currently requires that LRFP patients who seek an abortion must make at least two-in-person trips to the clinic-first for the state-mandated informed consent process, including a non-directive discussion regarding their options, and the second for additional, non-directive counseling and the abortion itself, after a mandatory delay of at least 48 hours (Id., ¶ 20). For patients receiving abortion care at 18 to 21.6 weeks LMP, which is a two-day procedure, that law results in at least three trips (Id.). Dr. Tvedten points out that a new law, set to take effect on July 24, 2019, increases the mandatory delay period to at least 72 hours (Decl. of Thomas Tvedten, M.D., ¶ 20 (citing Ark. Act. 801, to be codified at §§ 20-16-1109, -1703(b), -1706)).

         164. Dr. Tvedten is not a board-certified or board-eligible OBGYN (Id., ¶ 23). He cannot become either because he did not complete an OBGYN residency and cannot feasibly do so now, given “the extraordinary time and resources that would be needed to pursue a new specialty at this stage” of his career (Id. (citing Am. Bd. of Obstetrics & Gynecology, Candidate Requirements & General Details, Becoming an ABOG Registered Residency Graduate, https://www.abog.org/specialty-certification/general-cert-requirements-and-info#ContentC009Col00)). If the OBGYN requirement goes into effect, Dr. Tvedten will be forced to stop providing abortion care to his patients or risk incurring significant penalties (Id.).

         165. Dr. Tvedten also states that the only other physician currently providing abortions at LRFP every week is Dr. Horton, who lives in Memphis, Tennessee, and generally provides care at LRFP approximately one day a week (Decl. of Thomas Tvedten, M.D., ¶ 24).

         166. Dr. Tvedten further states that LRFP does not employ on a full-time basis or receive full-time assistance from any physicians who are board-certified or board-eligible OBGYNs (Id., ¶ 25). The only board-certified or board-eligible OBGYN who provides care at LRFP is Dr. Hopkins, but he can travel to Arkansas to provide abortion care at LRFP only approximately once every-other month (Id., ¶ 26).

         167. Dr. Tvedten states that, over the past four years, LRFP has undertaken significant efforts to try to find an OBGYN who would be willing to assist LRFP in continuing to provide abortion care, including by providing abortions at LRFP or on a part-time or full-time basis (Id., ¶ 27). These efforts included renewed efforts after the Arkansas legislature passed the OBGYN requirement (Decl. of Thomas Tvedten, M.D., ¶ 27). Despite their efforts, LRFP has not been able to identify a single board-certified or board-eligible OBGYN provider who can provide full-time or near-full-time care at LRFP (Id.).

         168. In Dr. Tvedten's experience, many of the physicians who provide abortion care in Arkansas permanently reside in other states and only travel to Arkansas to provide abortion care because there are no local physicians willing to provide abortion care here (Id., ¶ 28).

         169. According to Dr. Tvedten, locally-based physicians who do provide abortion care in Arkansas face stigmatization that may jeopardize their ability to continue to provide other care, retain positions or admitting privileges at hospitals, and protect their families from harassment (Id., ¶ 29).

         170. Dr. Tvedten states that one of the Arkansas physicians from whom he first received training in abortion care, Dr. James Guthrie, was forced to abandon his provision of abortion care altogether because of the harassment that he and his family practice partners faced at the hands of the anti-abortion activists who picketed his family practice clinic and the homes of the physicians with whom he shared this practice (Decl. of Thomas Tvedten, M.D., ¶ 30).

         171. Dr. Tvedten agreed to assist Dr. Guthrie in finding a replacement provider, and he eventually stayed on to provide abortion care on a permanent basis (Id., ¶ 31).

         172. Dr. Tvedten recalls conversations with his former medical school classmates, and he relates that “they scoffed at the idea of providing abortion care in the state, given the stigma associated with it and the accompanying risk that providing abortion would harm their ability to maintain the private practices and positions at hospitals.” (Id.).

         173. Dr. Tvedten also gave up his family practice in large part because of his knowledge that the political climate and stigma surrounding abortion care would make it extremely difficult, if not impossible, to attract potential partners and patients to a ...


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