Postcard from post-Roe Idaho

This story was published by Boise Weekly in two parts, on Oct. 24 and Oct. 31, 2024. It won first place in the Serious Feature category of the Idaho Press Club's Best of 2024 awards.

Idaho State Capitol in Boise. Courtesy photo.

Part I

Sheridan Brett had already done her crying when the doctor opened her chart and began to write. At the first inclination that something might’ve been wrong inside of her, Brett had crumpled to the floor of her home and wept, 10 weeks pregnant. She’d thought of her children’s joy at the thought of a new sister, and her own at the prospect of growing her young family. For the next two weeks, she’d leaned on hope, a ballast against the morbid calculus of life and death.

Earlier that week, a different doctor had taken a chorionic villi sample, a prenatal test common for older pregnancies. Brett, who’d had her first two kids without issue, saw no reason to think this time would be different. Something was. The test had shown there was a chance the fetus, a girl, would never make it out of the womb. Or she might survive a few days, or maybe even into childhood. There was also a chance—about a coinflip’s worth—that this worrying was for nothing, a false positive. Her girl could grow and thrive and join the family, child number three.

Brett had held tight to the happy half of her odds. By 12 weeks, the fetus was about the size of a plum, large enough to see in detail under ultrasound. She booked a scan and drove the 150 miles to Boise.

The St. Luke’s maternal fetal medicine office sits in an angular brick building in downtown Boise, a half-mile down Jefferson Street from the Idaho State Capitol. In Idaho, an overwhelmingly rural state, most maternal care is handled by family doctors closer to home; however, a small and shrinking fleet of specialists orbit the capital to handle high-risk patients like Brett. In the exam room, an ultrasound technician smeared gel on Brett’s stomach and moved the paddle until an image, black and white and blurred with motion, pulled into soft focus.

The tech, oblivious to Brett’s mounting anxiety, was bubbly: “Let’s look at this baby!” The woman counted: 10 fingers, 10 toes. Brett asked her to turn the monitor away. She had studied the science—papers, surveys, statistics—and couldn’t stand to look.

When he arrived, Brett’s doctor picked up details through the shades of gray. He saw telltale signs of cystic hygroma, a birth defect strongly linked with Turner Syndrome and bad outcomes. Looking closer, he saw fluid surrounding the fetus’ entire body. It filled the brain and the heart. It was clear to him that Brett’s baby had Monosomy X—Turner Syndrome—and possibly more complications. Scant few babies with this confluence of conditions survive to take a breath outside the womb. If they do, it’s rarely for long. Eyeing the scan, Brett’s doctor didn’t think hers would be one of them. Brett’s baby, just centimeters inside her belly, would never live to be a baby at all.

“They’d said, ‘This is a stillbirth,’” Brett remembered six months later.

“The chances of this baby surviving to birth, and surviving birth, are almost zero,” the doctor told Brett.

“What’s my percentage?” she asked.

“.001%,” the doctor said. “I can’t tell you there’s a zero-percent chance.”

She had hoped for good news, but that hope had floated like a film above a deep and complicated grief. She had mourned this loss for weeks, even as her baby grew, bobbing between sorrow and possibility.

As Brett sat in the Boise exam room, the calendar had just ticked over to July 2023. A year ago, the doctor later said, he would have cleared his schedule, put Brett in a gown, and ended her pregnancy that day. But Idaho had changed. So instead, he opened up Brett’s chart and began to type.

“I expressed my sincere condolences,” he wrote, “and wished Sheridan the best.”

*****

In August 2022, about six weeks after the U.S. Supreme Court ruled on Dobbs v. Jackson, Idaho’s standing trigger law outlawing abortion clicked into place. Amendments and a second law cinched up loopholes and raised the stakes. Courts have confirmed Idaho’s ban on abortion, effectively banning the practice at any stage. Women can no longer choose to end their pregnancies for their own reasons in Idaho, and that, according to lawyers, judges, and doctors alike, is no longer up for debate.

On paper, slim exceptions remain. In extreme cases, doctors are allowed to prescribe and perform a medically necessary abortion if, in their “reasonable” or “good faith medical judgement,” the mother bearing the child will likely die or lose a major bodily function. But those tasked with carrying out the procedure say they don’t know when they can provide abortion care, and when they’ll face punishment. As defined in state code, a doctor performing a “criminal abortion” can lose their medical license—six months for a first offense, permanently for a second—and face a minimum of two and a maximum of five years in state prison. Few, if any, doctors know when the state’s sparsely defined exceptions can be applied. Fewer still trust their livelihood and their freedom before a jury.

Put simply: When abortion is the treatment, when can someone be treated?

Two years since Idaho banned the procedure, doctors say this question has destabilized the state’s healthcare system. Providers and their patients remain lost in the new legal regime, navigating roads they say lawmakers have left stubbornly unmarked. Many doctors have closed shop and moved away, leaving Idahoans—already working with the fewest physicians per capita in America—scrambling to find obstetric care. Doctors and activists say the burden has fallen hardest on the patients least equipped to overcome it: poor women, rural populations, immigrants, refugees, people of color. With fewer doctors seeing more patients and minimal reinforcements in the pipeline, some physicians fear the state’s maternal health apparatus teeters on collapse.

Still, resistance continues. Doctors and patients have moved from the clinic to the courts, hoping to clarify, if not overturn, the terms of Idaho’s laws. In June 2024, the U.S. Supreme Court returned to lower courts a legal case out of Idaho, which is still expected to decide how emergency rooms can or cannot handle abortion care. At the state level, a case called Adkins v. Idaho aims to define what medical exemptions are available to doctors when their patients’ lives and wellbeing are on the line. Meanwhile, some Idahoans have built up their own infrastructure of support, finding angles for aid at the edges of what the state allows.

Now more than two years into the ban, while no doctor has yet faced charges under Idaho’s law, unless the rules begin to crystalize, physicians fear that’s not far away.

“It’s going to either be a woman who dies, or a doctor who goes to jail,” said Dr. Julie Lyons, a plaintiff in the Adkins case, “and no one is raising their hand for either.”

*****

Adkins v. Idaho was filed on Sept. 11, 2023, brought forth by a group of women—four patients and two doctors, including Lyons—alongside the Idaho Academy of Family Physicians. The case challenges the scope of medical exceptions under which Idaho’s interconnected bans allow abortions—situations, the plaintiffs say, that effectively don’t exist.

“In the 15 months since the Supreme Court overturned Roe v. Wade, Idaho’s reproductive healthcare infrastructure has spiraled into crisis,” the complaint begins. “A devastating combination of the most restrictive abortion laws in the country, predominantly rural geography, and an exodus of reproductive health care providers has left pregnant Idahoans with limited options for the basic healthcare they need to protect themselves and their families … . While Idaho’s abortion bans purport to contain ‘medical exceptions,’ these so-called exceptions simply do not function as such in practice.”

The case argues that vagaries in Idaho’s two abortion bans forced four of the plaintiffs out of state for healthcare. The filing describes each story in detail, Latinate legalese and medical diagnostics punctuating the plain vocabulary of pain.

For Jennifer Adkins, it’s the story of “Baby Spooky,” her second child, due on Halloween. Like with Brett, doctors saw in Adkins’ baby strong signs of Turner Syndrome. The fetus was unlikely to survive, doctors told her, but it did not miscarry like they expected. As it held on, risks to Adkins grew. Her odds of preeclampsia and edema rose—dangers to her future fertility, yes, but also her life. Had Idaho laws been different, her lawyers state, the doctors told Adkins they would have sent her to an abortion clinic in Boise, less than 30 minutes from her home. Instead, they did nothing at all. When her 12-week appointment still showed a heartbeat, doctors sent Adkins home with a miscarriage kit to confirm the diagnosis if she began to bleed.

On April 27, 2023, Jennifer and John Adkins left their 2 year old with grandparents. They’d pooled money from two abortion support funds to pay for a trip to Portland, Oregon. The procedure went as planned, and the pregnancy was over. Later, genetic testing from the miscarriage kit confirmed the Turner diagnosis.

“Ultimately, Mrs. Adkins and her husband know that traveling to Oregon to get the abortion care that Mrs. Adkins needed was the right decision for their family,” the lawsuit states. “Mrs. Adkins felt loved and cared for at the abortion clinic in Oregon. But her journey there left her feeling like a refugee—forced to flee her home state for basic medical care. Mrs. Adkins was angry that Idaho’s laws added needless grief, delay, and risk to an already awful experience. She felt compelled to tell her story publicly.”

The other women who joined the suit shared her struggle and her rage.

Kayla Smith sought out pediatric cardiologists in Boston, Denver and San Francisco, hoping that one knew a way to keep her baby—Baby Brooks—alive after birth. None did. Smith and her husband took out $16,000 in personal loans to pay for a trip to Washington to end their doomed pregnancy. On Sept. 6, 2022, Smith had an induction abortion at 21 weeks. She delivered Baby Brooks, stillborn, after 12 hours of labor.

Jilliane St.Michel learned at 20 weeks that her baby had a litany of developmental issues, and, her physicians said, no shot at life after birth. If the baby made it through delivery, it would move straight from the NICU to palliative care—hospice. An abortion in Seattle, she decided with her husband, was the most compassionate course.

Rebecca Vincen-Brown had been lightly bleeding for four weeks by the time a 16-week anatomy scan found that her baby’s development had veered off track. The list of abnormalities suggested triploidy; her child likely had 69 chromosomes instead of the typical 46. A triploidy pregnancy usually ends in an early miscarriage. If the baby survives outside the womb, it rarely lives for long. Facing a grim outlook, Vincen-Brown and her husband booked an appointment in Portland, Oregon. They couldn’t find anyone to watch their daughter, then 2, so she rode with them on the seven-hour drive. The next morning, Vincen-Brown began the first stage of her abortion—she took a pill—and headed back to the hotel.

“That night, Ms. Vincen-Brown could not sleep for hours because she began to experience labor contractions,” the lawsuit states. “Her husband stayed awake with her and spoke on the phone with the on-call doctor for the abortion clinic to ask for advice. At 4 a.m., Ms. Vincen-Brown ultimately passed her pregnancy in the hotel bathroom … They both had to be careful not to make any noise while their daughter slept.”

Genetic testing later confirmed triploidy; Vincen-Brown’s baby wouldn’t have survived.

In many ways, these cases went as well as they can for a woman in Idaho. Each woman had support, time, and at least some money behind them. They all lived in the Treasure Valley, Idaho’s population center, which boasts its densest concentration of doctors and quickest access to neighboring states with active abortion clinics. Between their abortions and the legal filing in September of ‘23, three of the four women were able to get pregnant again. It isn’t that way for everyone; rural mothers, poorer families and patients who do not speak English as a first language face greater risks, according to Lyons and Dr. Emily Corrigan, a Boise-based OB-GYN who is also listed among the plaintiffs. Lyons and Corrigan sued for clarity on their own behalf, as well as on behalf of their patients.

As Idaho’s maternal-fetal medicine workforce winnows—one result of the state’s legal landscape, according to a 2023 poll of physicians—the barriers to patient care, as well as the challenges to their practices, will deepen, they say.

“Inherently, when these laws are passed, they are applied differently to different people,” Dr. Misa Perron-Burdick told me outside the Ada County Courthouse in December 2023. Perron-Burdick had never been inside a courtroom before. But with a state motion to dismiss Adkins v. Idaho coming before Judge Jason Scott, she and five other OB doctors donned white lab coats and filed into Courtroom 507 in solidarity with the plaintiffs. Perron-Burdick strongly believes that abortion is a critical practice in maternal health. With more people leaving the state for the procedure, she flies back and forth to California for training to keep her skills sharp.

“Is Idaho a safe place to be pregnant?” I asked her.

“No.”

That’s the simple answer. The longer one: “It’s a safe place for people who have resources,” she said. She points to herself as an example. “I’m a physician—my family will always get the care they need. How do people who don’t have my resources get care? This targets Idahoans who are already struggling.” She thinks about people of color. The undocumented. Refugees—Idaho accepted the third most per capita of any state from 2013-2023, according to the nonpartisan Immigration Research Initiative, with many resettled in the southern tier of the state. These are people she sees regularly at Terry Reilly Health Services, a community health clinic that cares for patients with public insurance, or no insurance at all.

That’s where, last year, Perron-Burdick recalled treating a pregnant woman who was hemorrhaging blood. To Perron-Burdick, the treatment was clear: the patient’s health was at risk, the fetus unlikely to survive. But would it stand up to legal scrutiny, should it come to that? She waited. She needed to confirm there was no fetal heartbeat—that the pregnancy was no longer viable. She stood by.

“I cannot help you in this moment,” Perron-Burdick told the woman.

“I have two children at home,” the patient pleaded, bleeding. “Are you going to save my life?”

Perron-Burdick repeated the refrain. When she couldn’t find a heartbeat, she started the abortion, and the mother lived. But in that moment, waiting, the doctor said she had felt trust erode with her patient.

After replaying the story to me outside the courthouse, Perron-Burdick paused. “We’re in for a really long battle,” she said.

*****

When Dr. Lyons’ phone flashed Brett’s name, she was in and out of service, nestled in the northern reaches of the Idaho Panhandle. Lyons was no longer Brett’s doctor. She’d recently become the chief of staff at her home hospital in south-central Idaho’s Wood River Valley, and the new role changed the cadence of her family medicine practice. By then, though, the two women had become close. Two pregnancies together, two births. Small talk in the office, and later in the labor and delivery rooms. In between contractions, Lyons learned that Brett had studied at the same college, and they bonded further over their mutual alma mater.

Brett had sketched out Lyons’ agenda for the trip to the state’s expansive north, where Brett had grown up before heading east for school. And Lyons, in part, took the trip to find the landmarks of her friend’s youth.

Through the fits and gaps of one-bar reception, she realized this conversation wasn’t a check in. After hearing from her new doctor, Lyons was Brett’s first call. Lyons shifted into professional mode and gathered all the facts she could. Ten weeks. Samples taken. In her friend’s voice she heard the pragmatism she’d come to know, fractured, at points, with fear and confusion. From the details a diagnosis coalesced in Lyons’ mind: Turner Syndrome. She pushed it aside. Take the time, Lyons told Brett. At 12 weeks, an ultrasound will tell us more.

“This was at a point where we weren’t even sure if we could tell Sheridan she could go get an abortion without getting arrested,” Lyons said. “For me, it was never a question: I will help you get an abortion—I’ll go with you.”

Lyons lives in Idaho because she chose to train here. In the early 2000s, the Family Medicine Residency of Idaho boasted a strong program in maternal health. Primary care physicians are tasked with a broad range of care in rural states, and Lyons and her fellow residents were taught as such. From “day one,” Lyons began working with Planned Parenthood in Boise, the state capital and largest city. When the program placed her in Blaine County—a swath of central Idaho more than double the acreage of Rhode Island, with about an eighth of the population of Providence—she put that training to work.

“It was such a great women’s health track,” she said. “Not only did it train you in abortion care, it trained you in obstetrical care—the two main pieces of what I wanted to do as a provider. And now, both of those passions of my career have been ripped apart.”

The current state of things has made Lyons question whether she wants to continue. But medicine is her birthright. Lyons is a fourth-generation doctor, raised accompanying her father on house calls and hospital rounds in the Western Massachusetts hamlet of her youth. Today, Lyons carries her grandfather’s physician’s bag to the office. Her view of patient care, always expansive, has grown with her career. About half of her work is devoted broadly to obstetrics and women’s health, and she sees 30 to 40 pregnant patients each year. Her job, she says, is to stay with patients “from womb to tomb.” Lyons has personally cared for five generations of a single family—all women—and delivered the latest member herself.

Familiarity is an important aspect of rural medicine, Lyons said. To her, Idaho’s abortion laws steamroll it.

Until it became a felony, most abortions in Idaho were done by family doctors like Lyons. Early on, she performed the procedures in the clinic and at a second gig, moonlighting at Planned Parenthood in Twin Falls, an hour and a half south. She stopped about 10 years ago, when she was pregnant with her first child. Then as now, the climate was fraught. The picket line out front felt constant.

“I had this routine of trying to get into Planned Parenthood without getting shot,” she remembers, bobbing and dodging through the vestibule to her own macabre choreography. “I was so scared.”

She confessed this to her husband, a nurse. Lyons gave up that part of her career reluctantly, “but it was necessary, so I could have my own children, and feel safe about it.

“This is, unfortunately, not a new feeling in Idaho,” she said. “All of us—those who are on the frontline when it comes to this—have been fearful for years.”

Lyons had her first child, and then another. A few years ago, with her kids older, she felt comfortable going back. She called the Twin Falls Planned Parenthood, which was about to be one of two offices left in the state. They said no need, Lyons remembers. The bans were coming.

“They’d thrown in the towel,” Lyons said. They were right: Planned Parenthood of the Great Northwest, which oversees Idaho’s remaining chapters, would go on to lose the first major challenge to the new abortion ban at the Idaho Supreme Court in 2022.

*****

As staff cleared the exam room, someone handed Sheridan Brett a piece of paper. It listed places: Salt Lake, San Francisco, Santa Fe. These cities had places that could offer her an abortion, if she chose.

Brett studied the paper, composed herself as best she could, and asked if there was a quiet place to use the phone. She settled into an empty office.

Nonstop, Blaine County to Santa Fe is close to 16 hours by car. It’s quicker to drive from New York City to Atlanta. San Francisco, like going from Philadelphia to Chicago. Brett made some 60 phone calls from that room. She asked how far along they’d terminate a pregnancy, how much it would cost. She made a list. Eugene. Portland. Seattle. “When’s your next appointment?” In Portland, it was four weeks away. Eugene, same thing. Spokane, two weeks. In two weeks she’d be right at the limit of how far along the Spokane clinic would perform the procedure. Miss that date, she’d have to get to Seattle, and wait another three weeks for a slot. Spokane it was. She booked an $800 flight.

On the two-and-a-half hour drive back from Boise, Brett grieved. Going into her third pregnancy, she hadn’t been worried about the “1% shot” that things would go wrong. She weighed how much to tell the people closest to her, who to tell at all. Her family, of course. Her best friend, who was pregnant, too; they had been planning to go through it together. And her children, then 4 and 6, who had begun to picture life with a new sister.

“We were so excited,” Brett said months later.

“I was so excited,” Lyons added. “It’s a celebration.”

At home, Brett gathered her family.

“We told the kids that the baby inside mom was sick, and that happened sometimes,” Brett said. “And when I went on my trip, it was because the baby was sick and they had to get it out of me.”

The time slid by. Then she was on a plane to Washington. Spokane is on the Idaho border, close to where Brett grew up, and she had an aunt nearby to help. The older woman picked her up at the airport and dropped her at Spokane’s chapter of Planned Parenthood, a modern building encased in glass and wood veneer. There was one protestor out front.

Brett was there for five hours. She took a pill when she arrived, then sat in the waiting room. Forty-five minutes later, another pill. Two-and-a-half more hours waiting. A dozen or so women came through while she sat, some with partners or family or friends, others alone. When the pills had worked their course, a nurse called Brett to an exam room, where she was put under. She woke up weary. Someone had pulled her sweatpants back on. Her aunt parked out front and drove her away. From there the trip back was all that was left. As the crow flies, she was 325 miles from home.

Part II

Downtown Boise, with the the state Capitol in the back left. Unsplash photo courtesy of Alden Skeie.

Abortion was outlawed in Idaho before its statehood. Abraham Lincoln signed off on the Idaho Territory in March of 1863. From December of that year until February of the next, the state’s first territorial legislature worked to write its first laws. The terminology then was different: In code, an abortion was “procuring a miscarriage.” From the inaugural legislative session and through the decades that followed, abortion was illegal with exceptions. Physicians couldn’t be punished “who, in the discharge of his professional duties, deems it necessary to produce the miscarriage of any woman in order to save her life.”

Over the years, the vocabulary was refined and the statute simplified. Subsequent legislation changed “save” to “preserve,” but the general structure remained untouched. The abortion ban, as well as its exception, survived until 1973, when the U.S. Supreme Court’s decision on Roe v. Wade enshrined the right to an abortion in federal law. The Idaho Legislature, without “condoning or approving abortion or the liberalization of abortion laws,” complied with the ruling, and repealed its longstanding abortion ban.

But several conservative lawmakers sought to make Idaho’s rules as strict as they could under the new legal framework, according to minutes from the session. They passed what amounted to a trigger law: If federal rules changed, the state would fall back on its previous regulations. For the next 45 years, lawmakers periodically rewrote the law and added new ones, tightening restrictions as far as they could at the fringes of Roe’s battlements.

The overlapping abortion bans that now govern Idaho are not simple mirrors of the older laws. Each was written at different times using different language. For physicians, they present two different legal standards and separate avenues for punishment.

The Idaho Legislature passed a total abortion ban in 2020, two years before the U.S. Supreme Court overturned Roe v. Wade. Designed as a trigger law, it kicked in following the Dobbs v. Jackson decision in the summer of 2022. Where other states with similar legislation included carveouts for dangers to maternal health and cases of rape or incest, Idaho’s “Defense of Life Act” initially contained no exceptions. (Only Idaho and Tennessee wrote their laws that way.) Instead of exceptions, code outlined an “affirmative defense:” When brought to court, a doctor could present evidence that “in his good faith medical judgment … the abortion was necessary to prevent the death of the pregnant woman.” Provided a patient brought in a police report alleging rape or incest, the same approach would apply. If the affirmative defense passed muster in court, it waived criminal and civil liability, even though the abortion was still against the law. If not, doctors faced license suspension—six months for a first offense, permanent for a second—and between two to five years jail time.

That’s one of the two main laws in Idaho. The other, passed as the “Fetal Heartbeat Preborn Child Protection Act,” also kicked in after the Dobbs decision. From a criminal perspective, it’s largely redundant: Attorneys agree that the first, total ban takes precedence over what’s effectively a six-week abortion ban. But the second law outlines a new range of civil penalties and sets a different legal bar for doctors. A key difference, as written in code, is that a doctor’s defense against the six-week ban depends on proving they made a “reasonable” medical decision. According to the plaintiff’s filing in Adkins v. Idaho, a “reasonable” judgement is easier to attack than a “good faith” one. It isn’t hard to find a doctor on the other side of the aisle willing to testify to a peer’s malpractice, the argument goes. If a jury agrees, punishment follows. Civilly, the law allows for “any female upon whom an abortion has been attempted or performed, the father of the preborn child, a grandparent of the preborn child, a sibling of the preborn child, or an aunt or uncle of the preborn child” to sue for damages starting at $20,000 apiece.

When the laws kicked in, doctors were baffled. At the start of the 2023 Legislative Session, which opened soon after the new year, lawmakers heard consistent testimony outlining confusion in the medical field. Facing uproar, legislators set out to amend the ban. A political tug of war followed. Changes softened the ban, just slightly. An amendment converted the affirmative defense—which summoned doctors to court—into limited exceptions under which a doctor could perform a medically necessary abortion without risking trial. And the legislature drew up a new definition of abortion. It now states that a procedure is not a criminal abortion if its purpose is to remove “a dead unborn child,” to take out an ectopic or molar pregnancy, or to “a woman who is no longer pregnant.”

How long a fetus will survive outside the womb is irrelevant under the law.

“Rather,” writes James Craig, the Civil Litigation and Constitutional Defense Division chief for the Idaho Attorney General Raul Labrador arguing the Adkins case, “the Legislature has made a policy decision to ‘prefer, by all legal means, live childbirth over abortion,’ even in cases in which a physician believes that the child will die shortly after birth … . The statutes simply do not allow for an abortion in situations in which an unborn child is ‘unlikely’ to survive after birth.”

But doctors, critics like Lyons, say, deal in odds, not certainties. And health risks to a mother and baby are often enmeshed beyond parsing. Even if physicians could explain to lawmakers every possible fatal fetal diagnosis and the risks each poses to a mother, Lyons said, there are simply too many to codify, and there’s too much complexity in each case to capture in law.

“Physicians have been telling courts that they need discretion to practice medicine,” Marc Hearron, an attorney with the New York City-based Center for Reproductive Rights argued on behalf of the Adkins plaintiffs in December of ‘23. If a prosecutor “can come along with another expert—and there will always be another expert—it ties their hands.”

As for the patients, Hearron pointed to the first sentence of the Idaho Constitution: “All Idahoans, including pregnant Idahoans, are guaranteed three inalienable rights: enjoying and defending life and liberty; pursuing happiness; securing safety.”

“We’re not asking you to rewrite the statute,” he told Judge Scott. “We’re asking you to declare what their rights are as they relate to medical practice.”

To the state, the case was equally simple: It’s already decided. Idaho’s abortion laws as written have withstood legal challenge at the state’s highest court; the rest is policy, and that belongs in the legislature, not on the bench.

“Doctors are called upon every day to make life and death decisions—that’s part of being a doctor,” Craig told the judge in December. “That’s no different in cases of abortion. As long as they are acting in good faith, the decision cannot be second guessed.”

In Adkins v. Idaho, the plaintiffs are “asking for exceptions the legislature did not see fit to include,” Craig told the judge. The plaintiffs, it follows, need to come to court with concrete situations and individual conditions they’re seeking to clarify. Without those cases, the argument depends on “hypothetical facts, hypothetical scenarios,” Craig argued.

Judge Scott took the arguments under advisement. All rise. All exit.

In the hallway behind the courtroom, the doctors keyed in on one word: “Hypothetical.”

“Hypothetical—that’s hard to hear—especially when women this has happened to are sitting right there,” one physician said.

“This is not hypothetical,” added another.

Lyons, too, chewed on the term. Hypothetical? She believes that the confusion the laws have scrambled into the processes at her hospital are real enough. “There is so much dysfunction, because no one wants to go to jail,” she said. Since the laws were passed, she has rewritten how her staff care for pregnant women regardless of the details before them. It means more tests, extra ultrasounds. Added work, longer waits, higher costs. It’s as much about care as it is about building up a file of evidence for a legal case, should it someday come before a jury.

“It’s very real,” she said. “Nurses in the OB are scared. Everybody’s scared.”

Outside, Lyons stood with the plaintiffs. By the time she took questions from the press, she’d swallowed her anger. A doctor’s bedside manner translates outside the clinic, turns out, and she spoke with measured calm. But John Adkins, the lead plaintiff’s husband, didn’t appear to mask his anger. In a different world, he would be at home, preparing for Christmas. His second child would be a month old, turning two on New Year’s Eve. There would be no time for lawyers, no time for hypotheticals at all—just the galloping rhythms of a young family making room for one more. Instead, he put on a coat and tie and followed his wife to court.

A sixth-generation Idahoan, he lambasted the legislature through a long thatch of brick-red beard for their “culture war,” their “spiritual war,” the statement those in power wanted to use human lives—his wife’s life—to make.

“We are the casualties they are comfortable with,” he said. “We are their sacrificial lambs.”

*****

Kimra Luna was likely the first protestor arrested in Idaho after news of Roe’s overturn. The bans had not yet kicked in—the Jackson decision wasn’t even official, its terms leaked before the ruling was finalized—when Luna headed to Eighth Street in downtown Boise. The Nampa, Idaho, native was cited for leading a rally with a megaphone—a violation of noise ordinances, police said—and charged with a misdemeanor for obstruction for refusing to stop. (Both charges were dropped soon after.) Two of Luna’s three children, then 10 and 12, watched their mother taken to the ground, handcuffed and escorted away.

Two years earlier, sparked by the passage of Idaho’s six-week abortion ban, Luna had helped found Idaho Abortion Rights, an aid organization based in the Treasure Valley.

To Luna, who is in non-binary and uses they/them pronouns, the idea was to push past protest. With laws focusing on doctors, the group offers “community care,” they said. The organization’s volunteers aren’t medical professionals, Luna says, so under the law have no license to lose or jail time to face. It’s essentially a First Amendment campaign, emphasizing education, counseling and options—“basically,” they said, “taking care of each other and supporting each other the best we can.”

By the time the Boise Police cuffed Luna in 2022, they had remade their life in resistance to Idaho’s abortion laws. And when I spoke to them that May, Luna had worked with around 1,500 clients as Idaho’s principal abortion doula.

Luna had left home at 18, settled in bigger cities. Life was easier in New York or Seattle or Southern California, left-leaning centers where their gender identity and punk sensibilities—tattoos, piercings, ever-changing hair color—meshed with the culture like a raindrop blending into a stream. Luna promoted concerts, then launched their own venture as a marketing consultant and business coach. They made good money, but it wasn’t home. They were away 14 years before coming back to Nampa, 20 miles west of Boise, and settling into the house where their grandparents—a career potato processor and a head school custodian—lived in for 30 years.

Luna was anguished by where the state had drifted while they were away. They had hired doulas for their own pregnancies, then tried and failed to find one to help during and after an abortion in 2018. They decided to backburner their business to train for the “full spectrum” of the job—whether you wanted to keep your baby, or needed to end your pregnancy, they would help.

That job looks different now. The group isn’t secret or underground. Most people find Luna the way I did, through a flier in a coffee shop, or passed out at a shelter, or taped to a sympathetic storefront. The pamphlets have a website and the number for a channel on Signal, the secure messaging app. Luna gets daily texts:

“Is there a person I can talk to about my options?”

“Can I tell my mom about this?”

“I need help.”

There’s no typical client, and Luna gives no standard recommendation. They don’t ask for information from the client, so they only know what each woman offers. The bulk are women in Idaho, but Luna also works with clients in North Dakota, South Dakota and Nebraska. Often, callers are rural. Many aren’t fluent in English. Indigenous women living on Western reservations reach out about once a day. If the clients work, they tend to work low wage jobs—common in Idaho, which consistently ranks in the bottom quartile among states in earnings and claims the nation’s fifth highest wage gap between men and women, 75 cents on the dollar. (Wealthier people typically have the means, time and flexibility to find care on their own, Luna said.)

Some clients can’t locate a doctor. Maybe they want to find abortion pills online. Others need help signing up for Medicaid or WIC. Mostly, they want information: What they can expect as a pregnancy progresses, what might happen if it ends, and what resources are available either way. Every call is in its way unique. Luna passed the hat to raise a few hundred dollars for one woman who needed cab fare to pick up birth control at her P.O. box—it took an hour each way, and she didn’t have a car. In a couple of extreme cases, Luna flew with women to a clinic in Colorado where they ended their pregnancies—babies, they say, who would not have lived outside the womb. Both clients had never been on an airplane before.

For their differences, everyone who contacts Idaho Abortion Rights needs someone to talk to, which is in part how Luna settled on their preferred terms for what the group provides: mutual aid, and community care.

“I tell people all the time, I say I serve my community, 'cause I love my community,” they said. “I wouldn't be putting myself at risk—I wouldn't be dealing with people giving me death threats and rape threats in my social media DMs—if I didn't care about my community. Because I, I don't have to do this work. But to me, it's worth it for people to be able to get access to the care that they deserve and in the ways that they want.”

Luna is no more a politician than a doctor. They don’t expect Idaho law to be liberalized on abortion, and, these days, they don’t wade far into policy. They’re not trying to change laws; they’re trying to reach people. And, Luna says, it’s working.

“I tell people all the time, ‘We’re here.’ We’re not going anywhere. That’s the protest chant. We’re—we’re staying. We’re making sure people get access, whether that’s access to birth control, or help with their pregnancy, or getting an abortion. We’re doing it. To me, that is success.”

*****

Sheridan Brett still wants another child. Her kids more than ever want a little brother or sister. They tell her as much, with the candor of kindergarteners: “It’s time for you and Daddy to try again.”

Brett and I sat with Lyons on an early January day in 2024 in Ketchum, a small resort town in south-central Idaho. Outside, fat flakes of snow spun to the ground. The mountains around town were lost in cloud. The Idaho Transportation Department shut the highways to and from of the Wood River Valley; the wind seemed to move huge fins of snow wholesale, dropping them over the two-lane roads to the south. Flights were grounded. Lyons glanced outside. It was a bad day for an emergency, she said casually. There was no way in or out, whether you needed to get to the major trauma center in Boise or somewhere further, on a helicopter bound out of state.

As Brett told her story, Lyons scrolled through her phone. Her eyes welled. She was reading Brett’s chart.

“Your baby was due three days ago,” the doctor broke in.

“I know,” Brett said. “It’s OK. We’re going to get pregnant. We’re going to keep trying.”

“You shouldn’t be having this conversation. You—,” Lyons’ voice caught, “—you should be home with your newborn.”

“Yeah,” Brett said. She paused. “But that’s the thing. It wasn’t supposed to be a baby. It was never going to be a baby. That’s the whole point. Something went wrong. My body was supposed to get rid of it on its own, and it didn’t.”

“You needed the healthcare.”

“I needed the healthcare.”

Brett got it, eventually and at a high cost. But she said the physical and emotional trauma of carrying to term a baby born to die would have been much worse. Brett was healthy. She was managing the grief, coming to terms with the idea that her body had a problem it couldn’t solve on its own. In the process, she was finding that she wasn’t alone.

“You don’t find out that someone in your circle has had a miscarriage, or a pregnancy loss, or a problem with fertility—any of those issues—until you’ve spoken about it. And then you hear: ‘Me too. Me Too. Me too,’” she said. Out of her 10 closest friends, Brett said five of them have had at least one pregnancy loss.

“It has always been something that women keep as a private shame,” she said. “It’s like a club—but it’s a secret club. You don’t talk about your trauma, and your pain, and your difficulties, until someone else in the club tells them that it happened to them. You talk about it privately, and you keep it private. It’s passed between friends—it’s not public information ever. Ever.

“It’s not uncommon. It’s not an exception—it happens all the time. “

Lyons has delivered babies she didn’t expect to survive. She remembers one in particular. It had Trisomy 18, Edwards Syndrome, a chromosomal triplication that triggers a cascade of developmental problems. Lyons spent “an enormous amount of hours” trying to explain to the family what was going to happen. It happened anyway. The mother had complications but survived. The baby was born and immediately put on life support. Lyons kept the newborn breathing as an ambulance sped to Boise for advanced care, 100 miles away.

“I don’t think [the parents] understood until they got to Boise and saw that they’d turned the NICU into a hospice,” Lyons said. “Having to resuscitate a baby that is incompatible with life, so I can transport it to a place where it will die, is one of the most stressful things a rural doctor can go through. Trying to get this baby there, knowing that there’s no chance.”

In Boise, a team of neonatal doctors told the parents what Lyons had been trying to say: “We can’t keep this baby alive. You have to stop life support.”

In her darker moments, she imagines this happening again and again.

Lyons admits that doctors have done a poor job explaining the common role of abortion in healthcare. They prefer the terms of their training to the vocabulary of our politics. The language is technical to the point of euphemism. In conversation, Lyons does it, too. A clinical abortion is a form of “D&C,” “dilation and curettage.” A killer condition renders you “incompatible with life.”

“It’s probably true that of a lot of the general public doesn’t understand some of these fatal fetal diagnoses, and maternal health problems that arise,” Lyons said. “That’s probably the fault of the healthcare system: We haven’t labelled what we’ve been doing as abortion care, and now it looks terrible, even though it’s something we’ve always done forever. How do you educate to that? How do we teach the public to understand that their wives, sisters, daughters potentially face this risk, and that this is a standard medical procedure that is offered, and it’s often the most compassionate course?”

When we spoke in last winter, Lyons saw long odds against the court clarifying exemptions. Foremost, she saw Adkins v. Idaho as a chance to educate Idahoans on the role abortion plays in healthcare, and to crystalize in the public’s mind what happens when this one piece is removed.

“I don’t think any of us have any hope,” Lyons said. “I believe abortion will never be legal in Idaho again. If we are lucky, we might get a health exception. But right now, I think the future is focused on how we get women out of here when they need it.”

In June, Lyons announced a year-long sabbatical. Her term as chief of staff over, she’s taking time away from Idaho, first volunteering in Colombia, then seeing the world. When she comes back, she doesn’t expect to resume her full-scope family practice. She’s thinking about teaching, maybe in Boise, training the next generation of Idaho physicians.

“I always told myself when Roe fell, I was going to leave the country and I haven’t left yet. So why am I still here? I’m here because I feel like if I stay here, I have to express, I have to advocate and amplify the voices of women, otherwise I can’t live with myself. That was a promise I had to myself for too many years.”

“We can’t all run away,” Brett said.

“We can’t all run away.”

*****

Judge Jason Scott ruled on the state’s motion to dismiss Adkins v. Idaho earlier than expected. In the days before the new year, both sides claimed victory. Scott allowed the suit to continue but pared it down. The initial filing encompassed 314 paragraphs of allegations and five separate claims. Two claims remain for the court to consider in October 2024. For doctors hoping to define medical exemptions, the bones of the case are still intact. When it comes back, arguments will focus on the circumstances in which a physician can provide an abortion, and whether the Idaho Constitution entitles a woman to abortion care during a health emergency.

“This is only the beginning of this litigation, but the Attorney General is encouraged by this ruling,” Attorney General Raul Labrador’s office said in a statement. “He has long held that the named defendants were simply inappropriate, and that our legislatively passed laws do not violate the Idaho Constitution by narrowly limiting abortions or interfering with a doctor’s right to practice medicine. Attorney General Labrador will continue the fight to protect all Idahoans, including the unborn, and to uphold the laws passed by our legislature against special interest challenges.”

Gail Deady, a senior staff attorney with the Center for Reproductive Rights, issued a statement, too.

“We’re grateful the court saw through the state’s callous attempt to ignore the pain and suffering their laws are causing Idahoans,” she said. “Now the state of Idaho will be forced to answer to these women in a court of law.”

Lyons isn’t a natural optimist, she said. As the state’s 2024 legislative session dragged into the spring, she found little to hang her hopes on. Through three months at the statehouse, she watched efforts to clarify the abortion bans get “zero traction.” Meanwhile, the state “only went backwards when it comes to contraceptive care and mental healthcare,” she said.

There’s little indication that will change when a new legislature convenes in early 2025. Idaho’s Republican supermajority grew by one seat during the last statewide election in 2022, reaching 59 of 70 representatives and 28 of 35 senators. The Democratic party failed to field a candidate in 59 of 105 races that year.

If Idaho is to see changes in abortion policy, Lyons thinks it will have to come through a ballot measure. Idaho’s statewide referendum system has advanced progressive causes before, compelling lawmakers to expand Medicaid in 2018. Four years later, the legislature got in front of a popular ballot measure to spend more money on public schools by passing its own funding bill before voters could force its hand. Since, though, lawmakers have made it harder to get these questions before voters, changing code to require a broader base of signatories spanning more of the state to even get a question on the ballot. The fallout from the new ballot laws remains unclear. Either way, it would be years until voters could weigh in directly on abortion, if it got that far at all.

By then, physicians worry that maternal healthcare in Idaho may be broken beyond repair. Idaho has relatively few doctors to begin with. The most recent data dates to 2019, before Idaho’s trigger law passed and years before it took effect. Data from the National Institutes of Health found that Idaho had 19 doctors for every 10,000 residents, the worst ratio in the nation. Washington, D.C., the best, was 3.5 times higher. At the same time, Idaho had the third smallest concentration of med students per capita, coming in at less than half the national average, according to the Association of American Medical Colleges.

Conditions have deteriorated since those reports, said Dr. Loren Colson, spokesman for the Idaho Coalition for Safe Healthcare, a pro-physician lobbying group. In the first 15 months of Idaho’s total abortion ban, 58 OB/GYN doctors left the state—22% of all practicing obstetricians. Three hospitals closed their OB programs. As of April, just half of Idaho’s 44 counties had practicing OB doctors. Among maternal-fetal medicine specialists, who handle the most complicated pregnancies, attrition was worse. The state had nine when the ban became law. Now, it’s down to five. Replacements have proven hard to recruit.

“We’re exacerbating an already critical situation,” said Dr. Frank Batcha. “That’s very, very troublesome.”

Batcha is an assistant clinical dean at Idaho WWAMI, a partnership between Washington, Wyoming, Alaska, Montana, Idaho and the University of Washington Medical School to educate, train and place future physicians in these broadly underserved, overwhelmingly rural Western states. While applicants to medical school aren’t particularly focused on Idaho’s legal landscape—they just want to “put their best foot forward” to get in, he said—new medical school graduates are worried.

“They’re asking themselves, ‘Is this going to be a safe place to practice medicine?’” Batcha said.

He chooses his words carefully. Batcha makes it clear he’s not speaking for the university or as an assistant dean. A family doctor for more than 30 years, Batcha is now a public employee through his role at Idaho WWAMI. As a person paid by the state of Idaho, he’s not allowed to advocate for abortion under the 2021 “No Public Funds for Abortion” law. (A coalition of teachers and professors is currently challenging that provision of the law in court.)

People can disagree about when life starts, or the validity of “on demand” abortion, Batcha said. "That’s fine. But when we start talking about things that are actually going to cause harm to a woman, which much of the law does, that’s incredibly troublesome. Then what you’re doing is stratifying people’s worth. You’re saying that the worth of the fetus is greater than the worth of the mother. And I totally disagree with that.

“On top of that, we’re talking about criminalizing physicians for providing what is evidence-based healthcare? That’s very problematic.”

We may never know exactly what all this means for pregnant women in Idaho. The state is one of three in the nation not to centrally track major complications, known medically as severe maternal morbidities. Idaho’s Maternal Mortality Review Committee was tasked with scrutinizing the deaths of pregnant woman or new mothers and providing policy recommendations based on its findings. A year and six days after the Dobbs decision, on June 30, 2023, the committee’s charter lapsed. The legislature chose not to renew it. The committee’s final report covers data from 2021, ending eight months before Idaho’s abortion ban became law. Idaho is the only state in America that doesn’t systematically track maternal deaths.

*****

By May of 2024, something had changed in Sheridan Brett. Her grief was never linear. There were no neat stages, no clear rungs to climb towards hope. In the months following her abortion she struggled to make sense of it, swinging from confusion to fear to outright anger. Maybe now that pendulum was slowing to a stop.

Looking back, her turning point came by telling her story. In late January, Lyons invited her to a meeting of local reproductive rights advocates. Brett hadn’t planned to speak or rehearsed what she might say, but she shared everything. The room was full of women, most of them older, many with memories of the pre-Roe fights of the ‘60s and early ‘70s. Hearing Brett’s account, the crowd was whipped by déjà vu. They took her in.

“Every cliché applied,” she said. She woke up the next day “feeling 10 pounds lighter,” “energized,” “more engaged with my kids.”

She still feels the charge, the more she shares. She’s following that force. Brett has started organizing events that bring women together to talk about abortion care and reproductive health in Idaho. The first was a fundraiser for The Center for Reproductive Rights, which will continue arguing Adkins v. Idaho in October. She followed that up with a benefit for Idaho Abortion Rights, Luna’s group, which always needs items for its post-abortion care packages. Recently, as she watched a woman study the flier at a local coffee shop, she assured them the money was secondary.

“It’s more important that people say ‘abortion’ out loud,” she said.

Later this year, she’s planning to partner with the Pro Voice Project, a nonprofit founded by Jen Jackson Quintano, an arborist in Sandpoint, Idaho, to put on live stagings of abortion stories in Ketchum. She plans to tell her own.

Brett tends to think in unifying theories. She’ll see something on TikTok and trace its roots to the Agricultural Revolution. Part of what frustrates her about Idaho’s abortion ban is that she can’t quite see where the thinking begins or rationalize its ultimate goals. But, as she’s stepping up her advocacy, Brett finds herself trading these big connections for smaller ones.

“Modern society has forcibly isolated women in this country,” she said. “That’s not how it used to be. We used to meet. We used to gather. Women are stronger in groups.” She’s trying to make a community for herself, her friends, her neighbors, so they might see what strength lies there. She’s hopeful, for the first time in a long time, that something, someone might change.

“We just need to be a little louder.”