The highest court in Iowa ruled in favor of the state’s six-week abortion ban on Friday, effectively decimating access to care before many people even know that they are pregnant.

The law includes exceptions for the life of the pregnant woman and fetal abnormalities that would result in the infant’s death—allowances that medical professionals say are rarely implemented in practice.

Iowa’s ban also allows abortion in the case of rape or incest, but only when reported within 45 or 140 days, respectively. For rape or incest exceptions to be permitted, according to rules laid out by the Iowa Board of Medicine ahead of the court's decision, a doctor must acquire facts about how the pregnancy came to be and obtain a signed certificate that the information is true.

The decision “will have devastating impacts on already poor health outcomes in Iowa and force people into pregnancy,” Francine Thompson, executive director of the Emma Goldman Clinic in Iowa City, said. Planned Parenthood North Central States President and CEO Ruth Richardson said that the team has been preparing for this possibility for months. “Every person deserves to have the full range of sexual and reproductive health care they need, including abortion, no matter their ZIP code,” she said.

Until the new ban is officially implemented in about three weeks, Iowans can still get abortions in the state up to 20 weeks of pregnancy, according to the ACLU of Iowa.

“There is no right more sacred than life, and nothing more worthy of our strongest defense than the innocent unborn,” Republican Governor Kim Reynolds, who won re-election in 2022 by around 19 percentage points, said. Reynolds shared that she is "deeply committed to supporting women in planning for motherhood, and promoting fatherhood and its importance in parenting."

In a statement, President Joe Biden said the ban “puts women’s health and lives in jeopardy,” adding, “Vice President Harris and I believe that women in every state must have the right to make deeply personal decisions about their health.”

Access to abortion has been in flux for years in Iowa. In 2017, Republican legislators in the state passed a 20-week ban with a three-day waiting period (which a court later paused). In 2018, the legislature passed a 6-week ban, which a state court quickly granted an injunction against. That same month, the Iowa Supreme Court ruled that the three-day wait period violated the state’s constitution.

Fast forward to 2022, when the US Supreme Court’s decision in Dobbs set forth a new precedent for state legislators to utilize. Just four days after Roe was overturned, Governor Reynolds announced she would take the matter of abortion back to the state courts, using the Dobbs decision, to reinstate the six-week ban. The two years since have been filled with new iterations of the now-implemented law, court challenges, and a state of confusion for those seeking reproductive care in Iowa.

Iowa now joins 14 states that ban abortion in practically all cases and three other states—Florida, Georgia, and South Carolina—with 6-week gestational limits. Nationwide, 63 percent of Americans say abortion should be legal in all or most cases, according to Pew. And, a Des Moines Register/Mediacom Iowa Poll from 2023 found that 61 percent of Iowa adults say abortion should be legal in all or most cases.

Friday’s ruling addressed whether or not the state’s six-week ban would cause an "undue burden" on those seeking abortion care, a standard that Planned Parenthood had argued abortion bans are subjected to under the state constitution. This test comes from a 2015 case where the court had ruled, in accordance with some federal findings, that abortion restrictions were unconstitutional if they imposed a “substantial obstacle in the path of a woman seeking an abortion before the fetus attains viability."

In his majority opinion, Justice Matthew McDermott wrote, "Stated simply, we can find no principled basis under our due process precedents to apply the heightened scrutiny of an undue burden test to abortion." McDermott, who was appointed by Governor Reynolds, added, "Every ground the state identifies is a legitimate interest for the legislature to pursue, and the restrictions on abortion in the fetal heartbeat statute are rationally related to advancing them."

“The majority’s rigid approach relies heavily on the male-dominated history and traditions of the 1800s, all the while ignoring how far women’s rights have come since the Civil War era,” Chief Justice Susan Christensen wrote in her dissent. While the Iowa Constitution doesn’t refer to abortion, Christensen noted that “Other procedures affecting bodily integrity and medical care that are not specifically mentioned in our constitution include organ transplants and blood transfusions.”

Following the ruling, anti-abortion activists and politicians across the state rejoiced.

"I have been involved in pro-life for over 25 years in Iowa, and to think now that we will finally have protection for children is really hard to put into words," Maggie DeWitte, executive director of the anti-abortion group Pulse Life Advocates, said, calling the decision a "monumental win, for Iowa women, for Iowa families, for babies."

Iowa House Speaker Pat Grassley said in a statement “This ruling is a victory in the fight to protect unborn children in Iowa. The Legislature is elected by the people, and for too long, the courts have stood in the way of Iowans having their voices heard on this matter.”

Since the fall of Roe, states with more robust abortion protections have become lifelines for those forced to travel out of state for care. In the Midwest, that load has largely fallen on Chicago, Iowa’s neighbor. Since 2022, Planned Parenthood of Illinois (PPIL) said it experienced a 47 percent increase in the number of patients seeking abortion care—with 25 percent of all patients coming from other states. Before Dobbs, it was about 4 percent.

Julie Uhal, who oversees PPIL’s Abortion Expansion Program, said the organization is ready for a potential influx of patients from Iowa. “We have done enough capacity expansion work and we are ready to see patients from wherever they are coming from. We’re ready to support them with travel support funding, financial assistance,” Uhal said. “Yeah, we’re here and we’re not backing down anytime soon.”

Even prior to the court’s decision this week, Iowa lacked access to reproductive health care. As of 2022, according to data from the American College of Obstetrics and Gynecology, Iowa had the fewest number of OB-GYN specialists per capita of any state in the country. Out of the 99 counties in Iowa, 66 lack access to OB-GYN birth services.

“To be clear,” Justice Christensen dissent noted, “this trend will affect all pregnant women in Iowa—not just those seeking an abortion.”

“In my opinion,” Christensen wrote, “the only female lives that this statute treats with any meaningful regard and dignity are the unborn lives of female fetuses. After that, this statute forces pregnant women (and young girls) to endure and suffer through life-altering health complications that range from severe sepsis requiring limb amputation to a hysterectomy so long as those women are not at death’s door.”