Dr. Margaret Baum (second from left), chief medical officer for Planned Parenthood Great Rivers, stands with attorneys from the Planned Parenthood Federation of America on the steps of the Jackson County Courthouse in Kansas City, Missouri, on Jan. 12, 2026, the first day of a two-week trial over abortion restrictions. (Photo by Anna Spoerre/Missouri Independent)

The outcome of two trials in the coming weeks could shape what it will look like when voters overturn state abortion bans through future ballot initiatives.

Arizona and Missouri voters in November 2024 struck down their respective near-total abortion bans. Both states added abortion access up to fetal viability as a right in their constitutions, although Arizonans approved the amendment by a much wider margin than Missouri voters.

That was just the beginning of protracted legal battles.

Amy Myrick, senior counsel at the Center for Reproductive Rights, said ballot measures are a powerful and important step in returning abortion access to a state, but success on Election Day doesn’t mean the fight is over.

“State constitutions don’t automatically repeal laws,” Myrick said. “Sometimes, even if the state isn’t doing it, other groups or legislators will jump in to try to retain these restrictions.” 

The trial over Arizona’s abortion restrictions wrapped up this week, Arizona Mirror reported. Maricopa County Superior Court Judge Gregory Como seemed unconvinced of the argument that certain laws around how abortion medication can be prescribed, waiting periods and bans on abortions in cases of fetal abnormalities should remain enforceable.

A similar trial in Missouri will wrap up on Jan. 26 after hours of testimony about more than a dozen abortion restrictions state officials are seeking to preserve. The Republican supermajority state legislature is also putting a countermeasure to reinstate the abortion ban on the ballot in November, paired with a ban on gender-affirming care for minors. 

Arizona and Missouri have what are known by abortion-rights advocates as Targeted Regulation of Abortion Providers, or TRAP, laws passed by legislatures before the U.S. Supreme Court’s Dobbs decision in 2022. Even states without bans, like Connecticut, Maryland and Rhode Island, have statutes in place that the Guttmacher Institute considers TRAP laws. Abortion providers are subject to state licensing and other medical requirements, but as of December, 25 states still have laws that impose additional regulations for clinics, according to Guttmacher, such as facility size and transfer agreement requirements, or admitting privileges at local hospitals within 30 miles.

Officials and legislators usually argue in the statehouse and in court that the extra parameters increase the safety of abortion procedures, but the safety record is strong under existing medical requirements and is safer than childbirth, according to the American College of Obstetricians and Gynecologists. Studies show the risk of maternal death associated with childbirth is about 14 times higher than the risk associated with abortion.

But there are also other laws that advocates say are meant to discourage or frustrate those seeking abortion care, such as mandatory vaginal exams, waiting periods, or a requirement that the same physician must see an abortion medication patient over two subsequent visits. Some of those laws were passed over decades and helped drive abortion providers away, including in Missouri.

As a result, even though Missourians overturned the ban, abortion care remains difficult to obtain, and many are still leaving the state to get it, according to Missouri Independent.

“Because constitutional amendments don’t overturn conflicting laws, people can still experience injuries under these laws,” said Prachi Dave, senior managing legal and policy director at If/When/How, a reproductive rights legal services and advocacy organization. “For example, if a waiting period is interfering with my ability to access the care I am guaranteed under the newly passed amendment, then I would ask a judge to affirm that the law is getting in the way of my right. In doing so, lawsuits give practical effect to constitutional amendments.”

In a Michigan lawsuit led by advocacy groups, a judge ruled in May that a mandatory waiting period was unconstitutional after voters approved an initiative codifying reproductive rights.  

Wendy Heipt, attorney for advocacy organization Legal Voice in Washington, said even if some laws were ruled unconstitutional, they may have to be litigated again because the basis for the unconstitutional argument relied on the Roe v. Wade case that the U.S. Supreme Court overturned almost four years ago.

Heipt frequently works on cases in Idaho, where many lawsuits over the state’s near-total abortion ban have taken place in the past three years. Though still in effect, there is an effort to overturn the ban via ballot in November. 

The initiative is different from those approved in Arizona and Missouri because people in Idaho cannot submit constitutional amendments — only proposed state laws — for ballot consideration directly.

Melanie Folwell, lead organizer of the reproductive rights initiative in Idaho, said even if successful, it’s only one leg of a long race in restoring access. The initiative group, Idahoans United for Women and Families, drafted a bill that would have repealed existing abortion laws, but it was too long and legally complicated for the ballot. Instead, what they’ve come up with for voters is meant to establish a right to reproductive health privacy without undue government interference and override existing laws. 

The outcome of Missouri’s trial could be instructive for Idaho abortion-rights advocates, because the political environments are similar. Idaho has a lengthy list of its own waiting periods for abortion care, mandatory counseling and ultrasound requirements, and elected officials in the Republican-led state have repeatedly signaled their opposition to abortion access, including the attorney general. The legislature also has a Republican supermajority.

And since it can’t be a constitutional amendment, any new law may be more vulnerable to legal challenges. 

“There are things to learn from every one of the states that have reproductive access on the ballot, which is 17 states at this point,” Folwell said. “It is always instructive for us to see what plays out in that state’s legislature, what plays out with their courts.”

Myrick said the legal battles can feel discouraging, but voters shouldn’t let it stop them from using their voices to make their policy preferences known.

“Ballot measures are not the silver bullet. We need a lot of follow-up to make these rights real. And the attempts to keep these restrictions after the voters have spoken are blatantly anti-democratic, but they’re still happening,” Myrick said.

A trial over Missouri’s abortion regulations began Monday at the Jackson County Courthouse in Kansas City, Mo. Experts are watching the case, which could impact abortion access across the Midwest and South. (Photo by Kevin Hardy/Stateline)

KANSAS CITY, Mo. — The outcome of a trial over Missouri’s abortion regulations could ripple far beyond the state, potentially creating new availability for women in the Midwest and South who can’t access abortion close to home.

As a judge weighs the constitutionality of a litany of state restrictions on abortion, the stakes are clear for Missouri women: The decision could hamper access for nearly everyone in the state — or greatly broaden it in ways not seen in decades. That would allow women in a dozen nearby states with abortion bans to travel a shorter distance to access the procedure.

“Opening and reestablishing rights in the state of Missouri would help to alleviate some of the pressure that other states have since so many Southern states have banned abortion,” said Julie Burkhart, the co-owner of Hope Clinic in Granite City, Illinois. “It just seems logical that we would see a shift in migration patterns of patients in the country.”

At her clinic, about a 15-minute drive from downtown St. Louis, Missourians account for about half of all patients, Burkhart said. Though Missouri voters in 2024 enshrined a right to abortion in the state constitution, access has remained highly limited because of restrictive state laws. Only procedural abortions are available on a limited basis across three Planned Parenthood clinics in the state.

Many of those state laws face legal scrutiny this week as a Missouri judge weighs the constitutionality of regulations targeting abortion providers. Those include a 72-hour waiting period between initial appointments and procedures, mandatory pelvic exams for medication abortions and a ban on telemedicine appointments for medication abortions.

Planned Parenthood affiliates in Missouri argue state restrictions are unconstitutional under 2024’s voter-approved constitutional amendment. Over decades, state restrictions have gutted Missouri’s provider networks, limited appointment availability and ultimately forced abortions to a halt in 2022, before a limited number resumed after the 2024 vote.

Experts and advocates are closely monitoring the Missouri case, which is expected to be appealed regardless of the outcome, because of its practical implications on access in the region. While many women now rely on abortion medication, procedural abortion is still crucial for those seeking later-term abortions or who prefer an in-clinic procedure.

But the two-week bench trial in downtown Kansas City also tests lawmakers’ ability to put in place rules so restrictive that they effectively ban abortion — a practice used by anti-abortion lawmakers in other states looking to limit access to the procedure.

“Judges do not operate in a vacuum,” Burkhart said, “ … and we know for a fact that judges look outside the borders of their state for information and for guidance. I do see this as having national importance.”

That’s especially true in other states also litigating abortion access, including Arizona, Michigan and Ohio, said Rebecca Reingold, an associate director at Georgetown University’s O’Neill Institute for National and Global Health Law.

While state judges are not bound by the decisions of judges in other states, their deliberations can be informed by court rulings, particularly involving novel legal questions or areas of the law that are evolving.

“There is little doubt that advocates and decision-makers in other states navigating similar legal challenges are closely monitoring the litigation over Missouri’s abortion regulations,” Reingold said.

Restrictions targeting abortion

In the first days of the trial, Planned Parenthood leaders argued that ever-changing state laws and agency regulations have drastically limited access, caused needless red tape and posed privacy risk for their patients.

Dr. Margaret Baum, chief medical officer with St. Louis-based Planned Parenthood Great Rivers, said the Missouri requirements specifically target abortion rather than all other kinds of medical care.

“I provide vasectomies routinely. … And I am not required to have a complication plan, contact a primary care physician, even ask the patient how many miles they live from the health center.”

Opening day of Missouri abortion-rights trial focuses on decades of state restrictions

Baum said state-mandated reporting rules unique to abortion require clinicians to ask the race, education level, marital status and specific location of each patient — none of which is relevant to their care.

Planned Parenthood Great Rivers would like to offer abortion services in Springfield, Baum testified. Access in that region would provide an option for rural Missourians, and also could help serve residents in nearby Arkansas, Oklahoma and Texas, where abortion is almost universally banned.

But the organization’s facilities there do not meet state abortion regulations for physical attributes, including hallway size, doorway size and the number of recliners in recovery rooms, Baum testified.

Lawyers for the state defended Missouri’s restrictions as commonsense safeguards aimed at protecting vulnerable women. The attorney general’s office argued that complication risks of abortion justify additional state regulation — despite professional medical associations saying it’s generally safe. The AG’s office also maintained that Planned Parenthood faced a conflict of interest because of its financial motivations.

“Abortion is a business,” Deputy Solicitor General Peter Donohue said during a procedural argument on Monday. “Your Honor, the plaintiffs are asking to deregulate their profession in order to make more money.”

The state was expected to call as witnesses anti-abortion doctors and activists later in the trial.

Patients traveling for care

Since the U.S. Supreme Court’s ruling that overturned federal constitutional protections for abortion in June 2022, the number of abortions has increased slightly across the country, according to the health research nonprofit KFF.

The group points to expanded telehealth, which can offer medication abortion more affordably through virtual appointments.

Since the 2022 ruling and subsequent state abortion bans, patients have experienced higher travel costs for abortions and delays in care, according to research published in the American Journal of Public Health in July.

Researchers from the University of California, San Francisco found that travel time to access abortion increased from 2.8 hours to 11.3 hours for residents in states with abortion bans. Travel costs increased from $179 to $372. And more than half of survey respondents said their abortion care required an overnight hotel stay, compared with 5% before an abortion ban.

In 2024, an estimated 7,880 Missourians traveled to Illinois and 3,960 traveled to Kansas to access abortion, according to the Guttmacher Institute, a research and policy organization focused on advancing reproductive rights.

Those Missourians were among the approximate 155,000 people who crossed state lines to access abortion care that year, representing 15% of all abortions provided in states without total bans.

Ongoing uncertainty

Regardless of its outcome, the Missouri case is expected to be appealed. Even if the plaintiffs are ultimately successful, it may take a long time to restore care networks across the state, said Isaac Maddow-Zimet, a data scientist at the Guttmacher Institute.

“And that’s particularly the case when there are states that have a lot of legal uncertainty or restrictions coming into effect and then coming out of effect,” he said. “It’s not quick to open up a clinic. It’s not quick to even necessarily expand the kinds of services, or the kinds of the number of people that a clinic can see.”

Kimya Forouzan, the organization’s principal state policy adviser, said Missouri’s landscape is evidence that lawmakers can drastically curb abortion access without total bans. And despite an overwhelming vote to amend the constitution, legal battles can follow.

Even if the state’s laws are found unconstitutional, Forouzan said, lawmakers will likely still push anti-abortion measures. She noted that several bills have already been introduced in this year’s just-convened legislative session, and that Republican lawmakers are pushing a ballot measure to repeal 2024’s reproductive rights amendment.

“There’s very much a push to pass as many restrictions as possible and kind of see what happens later and how things shape up later. … Time will tell, but we do know that they’re still pushing forth restrictions,” she said.

Stateline reporter Kevin Hardy can be reached at khardy@stateline.org. Missouri Independent reporter Anna Spoerre can be reached at aspoerre@missouriindependent.com.