### In the



# United States Court of Appeals

For the Seventh Circuit

____________________

No. 17

‐ 1883

P LANNED P ARENTHOOD OF I NDIANA

AND K ENTUCKY

, I NC

., Plaintiff

‐ Appellee

,

v.

C OMMISSIONER OF THE I NDIANA S TATE

D EPARTMENT OF H EALTH

, et al.,

Defendants

‐ Appellants

.

____________________

Appeal from the United States District Court for the

Southern District of Indiana, Indianapolis Division.

No. 1:16

‐ cv

‐ 01807

— Tanya Walton Pratt

, Judge

.

____________________

A RGUED N OVEMBER 6, 2017

— D ECIDED J ULY 25, 2018

____________________

Before B AUER

, K ANNE

, and R OVNER

, Circuit Judges

.

R OVNER

, Circuit Judge

. Since 1995, the State of Indiana has

required that, at least eighteen hours before a woman has an

abortion, she must be given information provided by the

State about, among other things, the procedure, facts about

the fetus and its development, and alternatives to abortion.

That information is meant to advance the State’s asserted in

‐2 No. 17

‐ 1883

terest in promoting fetal life. In other words, the State hopes

that women who read that information and consider it will

opt not to have an abortion, and will, instead, choose to car

‐

ry the pregnancy to term. After she has received the man

‐

dated information, a woman must wait at least eighteen

hours before having an abortion, thus, the State hopes, she

will use the time to reflect upon her choice and choose to

continue her pregnancy. The State also requires that a wom

‐

an have an ultrasound and hear the fetal heartbeat prior to

an abortion although she may decline the opportunity to do

one or both, as 75% of women generally do. 1

Prior to July 1, 2016, women could, and generally did,

have the ultrasound on the same day of the procedure. This

was, in large part, because almost all abortions in Indiana

occur at one of four Planned Parenthood of Indiana and

Kentucky (PPINK) health centers, and only those few PPINK

facilities that offer abortion services (most do not) had the

ultrasound equipment on site. The Indiana House Enrolled

Act 1337 (HEA 1337), however, amended Indiana law and

now requires women to undergo an ultrasound procedure at

least eighteen hours prior to the abortion. Because of the

structure and location of abortion services in Indiana and the

population of women seeking abortions, this change—

moving the ultrasound from the day of the abortion proce

‐

dure to at least eighteen hours before—as we will explore, is

significant.

1 Prior to 2011, the law required that prior to an abortion the woman be

shown an ultrasound “upon the woman’s request.” P.L. 193

‐ 2011, Sec. 9.

In 2011 the legislature amended the statute to require that the woman be

shown the ultrasound unless she certified in writing that she did not

want to.No. 17

‐ 1883 3

PPINK filed suit against the Commissioner of the Indiana

State Department of Health and the prosecutors of Marion

County, Lake County, Monroe County, and Tippecanoe

County (collectively, “the State”), all in their official capaci

‐

ties. 2 PPINK claimed that HEA 1337 unconstitutionally bur

‐

dens a woman’s right to choose to have an abortion, and it

sought preliminary relief enjoining the provision during the

pendency of the litigation. The district court granted the pre

‐ liminary injunction. We agree with the well

‐ reasoned con

‐

clusions of the district court opinion, from which we borrow

heavily.

I.

A. Background information

1. The new law

Indiana Code § 16

‐ 34

‐ 2

‐ 1.1 mandates that at least eight

‐

een hours prior to the abortion procedure, the patient must

be provided with the following information (among others)

both orally and in writing: “that human physical life begins

when a human ovum is fertilized by a human sperm;” the

probable gestational age of the fetus at the time the abortion

is to be performed, including a picture of the fetus at certain

gestational ages, and other information about the fetus at its

2 Courts have long declared that abortion providers have standing to sue

to enjoin laws that restrict abortion. Planned Parenthood of Wisc., Inc. v.

Schimel

, 806 F.3d 908, 910 (7th Cir. 2015). “These cases emphasize not the

harm to the abortion clinic of making abortions very difficult to obtain

legally, though that might be an alternative ground for recognizing a

clinic’s standing, but rather the confidential nature of the physician

‐ patient relationship and the difficulty for patients of directly vindicating

their rights without compromising their privacy.” Id. (internal citations

omitted).4 No. 17

‐ 1883

current stage of development; notice that the fetus can feel

pain at or before twenty weeks; information about the risks

of abortion and of carrying the fetus to term, and infor

‐

mation regarding alternatives to abortion and other support

services available. Ind. Code § 16

‐ 34

‐ 2

‐ 1.1(a)(1)

‐ (2). A wom

‐

an seeking an abortion must also receive a color copy of a

brochure, authored and distributed by the Indiana State De

‐

partment of Health, that contains all of this same infor

‐

mation. The State controls every aspect of the information

conveyed to patients via this brochure—from the drawings,

to the color, information about development, and wording

of the risks of the procedures. Neither the brochure nor the

informed

‐ consent information has been challenged in this

litigation.

Prior to the enactment of the challenged law, Indiana re

‐ quired that “[b]efore an abortion is performed, the provider

shall perform, and the pregnant woman shall view, the fetal

ultrasound imaging and hear the auscultation of the fetal

heart tone if the fetal heart tone is audible,” unless the preg

‐

nant woman certified in writing, on a form drafted by the

Indiana State Department of Health, that she declined to

view the ultrasound or hear the fetal heart tone. Ind. Code

§ 16

‐ 34

‐ 2

‐ 1.1(b) (2011). In other words, the provider must of

‐

fer the ultrasound, but a woman may affirmatively decline.

Prior to 2011 the provider did not have to offer the ultra

‐

sound, but only had to provide one if specifically requested

by the woman. P.L. 193

‐ 2011, Sec. 9. In fiscal year 2016, only

approximately 25% of women seeking abortion services

chose to view their ultrasound images and only approxi

‐ mately 7% chose to listen to the fetal heart tone. Most im

‐ portantly for this litigation, before 2016, the statute did not

mandate when the ultrasound must occur, other than priorNo. 17

‐ 1883 5

to the abortion. As a practical matter, however, the ultra

‐

sound procedures were performed just before the abortion.

Ultrasound equipment is expensive and scarce. Not all

PPINK locations have it, but, at the time the new law was

enacted, the four locations that perform abortions had the

equipment. Although patients can receive their informed

‐

consent consultations at any one of the seventeen PPINK

health centers throughout Indiana, abortions are performed

only at four locations throughout Indiana (surgical abortions

are available only at three locations). Therefore, to prevent

women from having to travel far distances eighteen hours

apart, providers performed the ultrasound on the day of the

abortion procedure at one of the four facilities that had ul

‐

trasound and performed abortions.

The new statute, however, prevents this practice. It re

‐ quires the following:

At least eighteen (18) hours before an abortion

is performed and at the same time that the

pregnant woman receives the information re

‐ quired by subdivision (1), the provider shall

perform, and the pregnant woman shall view,

the fetal ultrasound imaging and hear the aus

‐

cultation of the fetal heart tone if the fetal heart

tone is audible unless the pregnant woman cer

‐

tifies in writing, on a form developed by the

state department, before the abortion is per

‐

formed, that the pregnant woman:

(A) does not want to view the fetal ultrasound

imaging; and6 No. 17

‐ 1883

(B) does not want to listen to the auscultation

of the fetal heart tone if the fetal heart tone is

audible.

Ind. Code Ann. § 16

‐ 34

‐ 2

‐ 1.1(a)(5). PPINK argues that this

requirement unduly burdens a woman’s right to an abor

‐

tion. Because PPINK’s argument is based on the factual con

‐

text, it is critical first to understand how PPINK health cen

‐

ters operate and where they are located.

2. PPINK facilities

At the time the law suit began, PPINK operated twenty

‐

three health centers in Indiana. Due to financial constraints,

that number has since dwindled to seventeen. Only four of

the centers offer abortion services—Bloomington, Indianapo

‐

lis, Merrillville and Lafayette—the latter of which offers only

non

‐ surgical abortions using medication. Of the centers that

offer abortion services, the times these services are available

are exceptionally limited. In Indianapolis, abortion services

are only available three days per week; in Merrillville, a day

and a half per week; and in Bloomington and Lafayette, only

one day a week. R. 24

‐ 1 at 6. PPINK will perform a surgical

abortion only until thirteen weeks and six days after the first

day of a woman’s last menstrual period. It will provide med

‐

ication abortions only until sixty

‐ three days after the first

day of a woman’s last menstrual period. Women who are

pushing up against the time deadline may not be able to

wait until a provider is available at the facility closest to

them, but may need to travel to a more distant facility where

a timely appointment can be made. The thirteen PPINK

health centers that do not provide abortion services provide

well

‐ women examinations, screening for cancer and sexuallyNo. 17

‐ 1883 7

transmitted diseases, treatment for sexually transmitted dis

‐

eases and other preventative health care.

There are no clinics in Indiana that perform abortions

past these dates. The only providers of abortion services af

‐

ter these dates are hospitals and surgical centers (all of

which happen to be located in Indianapolis) and those facili

‐

ties generally only provide abortions that are medically indi

‐

cated because of a fetal anomaly or a threat to a woman’s

health, and these are quite rare. Out of the 7,957 abortions

performed in Indiana in 2015 (the year before enactment of

the new law), only 27 occurred in a hospital or surgical cen

‐

ter. Only eighteen occurred after thirteen weeks. Indiana

State Department, Terminated Pregnancy Report—2015, at

pp. 7, 17, 18 (released June 30, 2016). Available at

https://www.in.gov/isdh/files/2015%20TP%20Report.pdf

[Last visited June 19, 2018].

PPINK has attempted to expand its health services

throughout Indiana, but it operates only seventeen centers

spread across a large state and only four that provide abor

‐

tions. This means that some women must travel great dis

‐

tances to obtain an abortion. For example, Indiana’s second

largest city, Fort Wayne, had a PPINK health center until Ju

‐ ly 9, 2018, but it did not provide abortion services. Now it

has none. 3 The closest center providing such services is 115

miles away in Lafayette (a more than two hour drive). 4

3 PPINK anticipates reopening another clinic in Fort Wayne although it

does not have a timeframe for doing so. See Appellate Record at 51,

PPINK Citation of Additional Authority, 7/12/18.

4 According to Google Maps, the distance from Fort Wayne to the ad

‐

dress of the PPINK clinics is as follows:8 No. 17

‐ 1883

There are also no out

‐ of

‐ state abortion clinics that are close

to Fort Wayne.

Prior to the enactment of the challenged law, women

seeking abortions could have their state

‐ mandated in

‐

formed

‐ consent session at any one of the seventeen centers

across the state. At this appointment, which usually only

lasted about fifteen minutes, health care providers also cal

‐

culated the gestational age of the fetus based on the length of

time from the first day of the last menstrual period. To make

it more convenient for patients, PPINK allowed parents to

bring children to these appointments. Women could then

have an ultrasound, as required by then

‐ existing state law,

on the day of the procedure at the health center providing

the abortion. PPINK would use that ultrasound information

to verify that the pregnancy was intrauterine (and not ectop

‐ ic) and to verify the gestational age to insure that the abor

‐

tions are being performed within the required limits. An ul

‐

trasound is not medically necessary prior to an abortion, but

the state requirement to perform an ultrasound is not chal

‐ lenged in this case, just the timing of it. Allowing the in

‐

formed consent to be performed at any of the PPINK centers

made it practical for women who live a long distance from

the few centers that offer abortion services, by eliminating

the need for multiple visits.

Merrillville: 124 miles

Lafayette: 115 miles

Indianapolis: 122 miles

Bloomington: 203 miles

R. 24

‐ 1 at 3.No. 17

‐ 1883 9

Once the new law was enacted, requiring that the ultra

‐

sound take place at least eighteen hours prior to the abor

‐

tion, the barriers for many women increased significantly.

Because ultrasound machines were only available at the four

PPINK centers that provide abortion services, women who

lived a significant distance from one of those centers were

faced with two lengthy trips to one of those facilities or an

overnight stay nearby. PPINK attempted to ease that burden

by purchasing one additional ultrasound machine for one

health center that does not offer abortion services, and

trained a staff member to use ultrasound equipment at an

‐

other. Those expenditures exacted a heavy toll on the financ

‐

es of the organization, and still did not ease much of the

burden. The ultrasound machines PPINK uses cost approx

‐ imately $25,000 and must be operated by trained technicians.

National Planned Parenthood policies, which are designed

to align with generally accepted medical standards, require

that an ultrasound image be interpreted by a physician or an

advanced practice nurse. The nurse

‐ practitioners at PPINK

do not have the requisite training and PPINK asserts that it

can afford neither the cost nor time to enroll nurses in the

four

‐ week training program.

3. Population served

The majority of women who seek abortion services at

PPINK (and for that matter, the rest of the nation) are poor.

The table below demonstrates the income level of patients

relative to the federal poverty line (FPL). 5

5 Poverty experts generally use 200% of the federal poverty line as an

approximation of the income necessary to survive on one’s own. R. 24

‐ 210 No. 17

‐ 1883

Income % of p a

‐

Unknown 22%

0

‐ 100% 37%

101

‐ 150% 11%

151

‐ 200% 8%

201

‐ 250% 5%

251+% 16%

R. 24

‐ 1 at 14. These women often have precarious employ

‐

ment situations and generally are not paid for days they do

not work. Many of them already have one or more children.

In 2016, 33.73 percent of PPINK patients reported that they

had children living with them. R. 24

‐ 1 at 4–5.

4. The district court’s decision

The district court carefully weighed the burdens identi

‐

fied by PPINK against the benefits the State hoped would

accrue to its citizens—the protection of both fetal life and the

mental health of women. It concluded that:

The new ultrasound law creates significant fi

‐

nancial and other burdens on PPINK and its

patients, particularly on low

‐ income women in

Indiana who face lengthy travel to one of

PPINK’s now only six health centers that can

offer an informed

‐ consent appointment. These

burdens are clearly undue when weighed

against the almost complete lack of evidence

that the law furthers the State’s asserted justifi

‐

cations of promoting fetal life and women’s

mental health outcomes. The evidence present

‐

ed by the State shows that viewing an ultra

‐

at 4. Many experts describe those at or below 100% of the federal poverty

line as “poor” and those between 100% and 200% as “low income.” Id.No. 17

‐ 1883 11

sound image has only a “very small” impact

on an incrementally small number of women.

And there is almost no evidence that this im

‐

pact is increased if the ultrasound is viewed

the day before the abortion rather than the day

of the abortion. Moreover, the law does not re

‐ quire women to view the ultrasound imagine

[sic] at all, and seventy

‐ five percent of PPINK’s

patients choose not to. For these women, the

new ultrasound [law] has no impact whatsoev

‐

er. Given the lack of evidence that the new ul

‐

trasound law has the benefits asserted by the

State, the law likely creates an undue burden

on women’s constitutional rights.

Planned Parenthood of Ind. & Ky., Inc. v. Comm ʹ r, Ind. State

Dep ʹ t of Health

, 273 F. Supp. 3d 1013, 1043 (S.D. Ind. 2017).

B. The legal standard

We review the district court’s grant of a preliminary in

‐ junction in this case for an abuse of discretion, reviewing le

‐ gal issues de novo, factual findings for clear error, and giv

‐ ing deference to the district court’s weighing of the evidence

and balancing of the equities. Whitaker By Whitaker v. Kenosha

Unified Sch. Dist. No. 1 Bd. of Educ.

, 858 F.3d 1034, 1044 (7th

Cir. 2017).

To obtain a preliminary injunction, PPINK must establish

that it has some likelihood of success on the merits; that it

has no adequate remedy at law; that without relief it will

suffer irreparable harm. City of Chicago v. Sessions

, 888 F.3d

272, 282 (7th Cir. 2018). If that burden is met, the court must

weigh the harm that the plaintiff will suffer absent an injunc

‐12 No. 17

‐ 1883

tion against the harm to the defendant from an injunction,

and consider whether an injunction is in the public interest.

Id. Our court employs a sliding scale approach, “The more

likely the plaintiff is to win, the less heavily need the balance

of harms weigh in his favor; the less likely he is to win, the

more need it weigh in his favor.” Valencia v. City of Spring

‐ field

, 883 F.3d 959, 966 (7th Cir. 2018) (internal citations omit

‐ ted).

The district court correctly noted that the need for and

propriety of a preliminary injunction of this law would de

‐ pend mostly on the likelihood of success on the merits. It

therefore focused most of its attention, as do we, on that fac

‐

tor.

II.

A. The test articulated in Casey and Whole Women’s

Health

The basic premise from which we must begin our review

of the district court opinion is that the Supreme Court has

recognized and affirmed “the right of the woman to choose

to have an abortion before viability and to obtain it without

undue interference from the State

... [without] the imposi

‐

tion of a substantial obstacle to the woman’s effective right

to elect the procedure.” Planned Parenthood of Se. Penn. v. Ca

‐

sey

, 505 U.S. 833, 846 (1992). But yet, “[t]he fact that a law

which serves a valid purpose, one not designed to strike at

the right itself, has the incidental effect of making it more

difficult or more expensive to procure an abortion cannot be

enough to invalidate it.” Id. at 874. How then, do we deter

‐

mine whether a law’s effects are incidental or unconstitu

‐ tionally limiting? The Casey court set forth an undue burdenNo. 17

‐ 1883 13

test which declared that a state may not establish a regula

‐

tion that “has the purpose or effect of placing a substantial

obstacle in the path of a woman seeking an abortion of a

non

‐ viable fetus.” Id. at 877. As the Casey court explained,

A statute with [an improper] purpose is invalid

because the means chosen by the State to fur

‐

ther the interest in potential life must be calcu

‐

lated to inform the woman’s free choice, not

hinder it. And a statute which, while further

‐ ing the interest in potential life or some other

valid state interest, has the effect of placing a

substantial obstacle in the path of a woman’s

choice cannot be considered a permissible

means of serving its legitimate ends.

Id

. Recently, the Supreme Court reiterated this test noting

that Casey held that a law is unconstitutional if it imposes an

“undue burden” on a woman ʹ s ability to choose to have an

abortion, meaning that it “has the purpose or effect of plac

‐ ing a substantial obstacle in the path of a woman seeking an

abortion of a nonviable fetus.” Whole Woman ʹ s Health v. Hel

‐

lerstedt

, 136 S. Ct. 2292, 2324 (2016), (citing Casey

, 505 U.S. at

877).

Importantly, both Whole Women’s Health and Casey stress

that the undue burden test is context specific. Id. at 2306; Ca

‐

sey

, 505 U.S. at 885. An abortion statute valid as to one set of

facts and external circumstances can be invalid as to another.

Whole Women’s Health

, 136 S. Ct. at 2306.

The State argues that the test for weighing abortion regu

‐

lations differs depending on the purpose of the statute and

that Casey and Whole Women’s Health establish different tests14 No. 17

‐ 1883

depending on the nature of the regulation. The State claims

that under Casey

, an informed

‐ consent and waiting period

law will only be invalidated if the regulations “impose a

‘substantial obstacle in the path of a woman seeking an abor

‐

tion.’” Appellant’s Brief at 26 (citing Casey

, 505 U.S. at 877).

This standard, it argues, is somehow different than the un

‐

due burden test of Whole Women’s Health which, the State

says, is only appropriately applied to regulations that osten

‐ sibly promote women’s physical health. Appellant’s Brief at

17. The State claims that the balancing test is not appropriate

here because, unlike in Whole Women’s Health

, the parties’

stated interests are fundamentally opposed—the plaintiffs’

goal is to help women carry out their decisions to terminate

a pregnancy and the State’s goal is to persuade a woman to

reconsider that decision. Regulations that address informed

‐

consent and waiting periods, the State argues, are subject on

‐ ly to “demonstration that they will cause a significant de

‐

cline in abortions unrelated to the persuasive impact.” Ap

‐ pellant’s Brief at 22.

The State is incorrect that the standard for evaluating

abortion regulations differs depending on the State’s assert

‐

ed interest or that there are even two different tests—the

undue burden test of Whole Women’s Health and a less

‐ exacting “substantial obstacle” test (as the State argues) de

‐

rived from Casey

. To the contrary, Casey described the undue

burden test as “a standard one of general application,” and

equated the “substantial obstacle” with “undue burden” not

‐ ing that “[a] finding of an undue burden is shorthand for the

conclusion that a state regulation has the purpose or effect of

placing a substantial obstacle in the path of a woman seeking

an abortion of a non

‐ viable fetus.” Casey

, 505 U.S. at 876–77

(emphasis ours). In fact, in Casey’s seminal iteration of theNo. 17

‐ 1883 15

undue burden test, the Court applied it to all of the regula

‐

tions at issue in that case, including those that the state

claimed affected women’s health (record keeping and re

‐ porting), but also to spousal notification and parental in

‐

volvement, which the state asserted were related to its inter

‐

est in potential life. Id. at 887–99. In other words, the Casey

Court applied the same undue burden test to all of the regu

‐

lations at issue in that case without regard to the state’s as

‐

serted interest. In fact, Casey made clear that “a statute

which, while furthering the interest in potential life, or some

other valid state interest

, has the effect of placing a substantial

obstacle in the path of a woman’s choice cannot be consid

‐

ered a permissible means of serving its legitimate ends.” Id.

at 877 (emphasis added).

Nor is there anything in the Court’s decision in Whole

Women’s Health to suggest that it applied a different standard

than the undue burden test articulated in Casey

. Rather, the

Whole Women’s Health Court clearly states to the contrary.

When discussing “undue burden” it starts with the sentence,

“We begin with the standard, as described in Casey ” and

then goes on to note how it will apply that standard: “The

rule announced in Casey [] requires that courts consider the

burdens a law imposes on abortion access together with the

benefits those laws confer.” Whole Women’s Health

, 136 S. Ct.

at 2309. And in fact, in announcing this rule, the Court cited

specifically to the balancing the Casey court did for provi

‐

sions not justified by a concern for women’s health—those

related to spousal notification and parental consent. Id. (cit

‐ ing Casey

, 505 U.S. at 887–98, 899–901).

Not only does Whole Women’s Health confirm that courts

must apply the undue burden balancing test of Casey to all16 No. 17

‐ 1883

abortion regulations, it also dictates how that test ought to

be applied. Citing Casey

, the Whole Women’s Health Court

emphasized that the undue burden test requires courts to

“retain[] an independent constitutional duty to review factu

‐

al findings where constitutional rights are at stake.” Whole

Women’s Health, 136 S. Ct. at 2310. In other words, a court

cannot merely depend on legislative statements and findings

in evaluating the constitutionality of laws regulating abor

‐

tion. Id. The proper standard is for courts to consider the ev

‐

idence in the record—including, expert evidence. Id. And, as

we discuss next, this is precisely what the district court did

below.

B. The evidence of burdens and benefits

1. Burdens

Noting the Supreme Court’s mandate to consider the ev

‐

idence in the record and then weigh the asserted benefits

against the burdens, the district court did just that; it made

findings and evaluated the persuasiveness of the evidence

regarding the burdens and benefits created by the new ultra

‐

sound law. 273 F. Supp. 3d at 1021 (citing Whole Women’s

Health, 136 S. Ct. at 2310). Beginning with the burdens, the

district court considered the burdens as presented by

PPINK, focusing first on the proper population to consider,

and then considering how the new regulations impact fi

‐

nances, employment, child care, and the safety of women in

abusive relationships.

As the district court noted, “[t]he proper focus of consti

‐

tutional inquiry is the group for whom the law is a re

‐

striction, not the group for whom the law is irrelevant.” Id. at

1021 (citing Casey

, 505 U.S. at 894). In this case, as the districtNo. 17

‐ 1883 17

court correctly determined, the new ultrasound law is a re

‐

striction primarily for women for whom an additional

lengthy trip to a PPINK health center for their informed

‐

consent appointment acts as an impediment to their access

to abortion services. The district court found specifically that

this group consisted of low income women who do not live

near one of PPINK’s six health centers where ultrasounds

are available. We agree with the district court on this point,

but also note that the concerns about confidentiality in em

‐ ployment situations and abusive spouses that we address

further below, can create impediments that span income lev

‐

els. Nevertheless, our analysis, like the district court’s, does

not rely upon this larger group.

All of the burden in this case originates from the lengthy

travel that is required of some women who have to travel far

distances for an ultrasound appointment at least eighteen

hours prior to an abortion. Recall that before the enactment

of the new ultrasound regulation, all women seeking an

abortion had to travel some distance to the nearest PPINK

facility at least eighteen hours prior to an abortion in order

to participate in an informed

‐ consent information session.

Because the law did not require that women have an ultra

‐

sound until just before the abortion procedure, however,

they could participate in that informed

‐ consent meeting at

any of the twenty

‐ three PPINK facilities spread throughout

Indiana. 6 Now, however, they must travel on the day prior

to the abortion, to one of six PPINK facilities that has ultra

‐

sound equipment. As we noted above, this means that some

women must travel great distances twice in order to receive

6 Due to budget problems there are now only seventeen PPINK facilities

in Indiana.18 No. 17

‐ 1883

an abortion. For example, women in the second largest city

in Indiana, Fort Wayne, must now travel approximately 400

miles over two days to obtain an abortion, as the closest ul

‐

trasound machine is 87 miles away in Mishawaka (174 miles

round trip) and the nearest abortion

‐ providing health center

is 115 miles away in Lafayette (230 miles round trip). R. 24

‐ 1

at 3, 13–14. Previously, when Fort Wayne still had its non

‐

abortion

‐ providing health clinic, women in Fort Wayne

could have their fifteen

‐ minute

‐ long informed

‐ consent ap

‐ pointment right at the PPINK health center in Fort Wayne.

Although the travel distance is the origin of the burden,

the district court found that the strain of the law extends into

the realm of finances, employment, child care, and domestic

safety. The district court considered the testimony of

PPINK’s expert in gender studies, poverty, and low

‐ wage

labor markets, Dr. Jane Collins, who explained the impact of

the new law on these interconnected stressors and on the al

‐ ready precarious financial lives of poor women seeking an

abortion. R. 24

‐ 2. She analyzed the family budgets of low

‐

income women and assessed how the additional costs asso

‐

ciated with the new ultrasound law would impact these

women and their families. Her testimony confirmed what

common sense suggests. Many low

‐ income women do not

have employment that pays them when they miss a day of

work or they may have precarious job situations in which

they could be fired for excessive absences. A second lengthy

trip for an ultrasound appointment likely requires a second

missed day of work. And women with young children who

could previously bring them along to an informed

‐ consent

session must leave them behind for the ultrasound, as

PPINK’s policies prohibit children from being present dur

‐ ing an ultrasound. (And as we discuss below, both safetyNo. 17

‐ 1883 19

and common sense support such a policy). The new ultra

‐

sound law therefore requires women to arrange child care

for an additional day.

Dr. Collins calculated that the additional cost posed by

the new ultrasound law for a woman living in Fort Wayne,

Indiana who has children, no car, and would lose a day’s

wages would be between $219 to $247. R. 24

‐ 2 at 18. Many

low

‐ income families have a discretionary monthly budget of

approximately $40. Id. The additional expenses of over $200

constitute roughly 25% of their entire monthly budget. Id.

These expenses are above and beyond the cost of the abor

‐

tion itself which was, at the time of the hearing, $410 for the

abortion and $100 for the ultrasound. R. 24

‐ 1 at 8; R. 35

‐ 5 at

35. Dr. Collins explained that to cover the costs associated

with abortions, many women (about one third) will delay or

stop paying basic bills in order to afford an abortion. R. 24

‐ 2

at 21. Up to 50% of women borrow money from family and

friends. R.24

‐ 1 at 20. The district court concluded that, “for

many women faced with the already high costs of an abor

‐

tion and a lack of means to afford them, the additional ex

‐

penses of lengthy travel, lost wages, and child care created

by the new ultrasound law create a significant burden.” 273

F. Supp. 3d at 1028.

The cost of the ultrasound rule is measured not only in

dollars but in time and access as well. Surgical abortions are

available at PPINK health centers until thirteen weeks and

six days after the last menstrual period. In fiscal year 2016,

approximately 22% of all abortions and more than 34% of

surgical abortions performed at PPINK took place in the

three weeks before the deadline. R. 24

‐ 1 at 7–8. Women often

push up against the deadline because they are gathering the20 No. 17

‐ 1883

necessary funds, making logistical arrangements or because

they failed to promptly recognize the signs of pregnancy.

R. 24

‐ 1 at 7–8. (Most women cannot know they are pregnant

until at least 4 weeks following their last menstrual period,

thus reducing the time they have to discover the pregnancy,

explore their options and discuss them with a partner, fami

‐ ly or doctor, arrange for missed work and child care, and se

‐

cure two appointments—to only nine weeks, 6 days for a

surgical abortion and thirty

‐ five days, for a medical abor

‐ tion).

Before the new ultrasound law, PPINK could usually ac

‐

commodate women imminently facing the deadline by

scheduling an informed

‐ consent appointment at the nearest

PPINK health center and then, the next day, she could travel

the further distance, if necessary, to a PPINK facility that of

‐

fered abortion services. After the enactment of the new law

(and before the district court issued a preliminary injunc

‐

tion), the PPINK health centers with ultrasound machines

became so overwhelmed with appointments that PPINK

could not adequately respond to women who contacted

PPINK near the end of the allowable time period. As a re

‐

sult, PPINK had to double book appointments causing fur

‐

ther delays for women and longer wait times for women

who were already missing work time and needing to ar

‐

range child care. Even with overscheduling, appointment

availability grew scarce and women had to wait longer to

have an abortion. This precluded the option of medication

abortions for some women and any abortion choices for oth

‐

ers. Abortion appointments were already scarce in Indiana

given that physicians are only available at the four health

centers offering abortions at limited times: Indianapolis (3

days/week); Bloomington (1 day/week); Merrillville (1.5No. 17

‐ 1883 21

days/week); and Lafayette (1 day per week). R. 24

‐ 1 at 6.

With such limited availability, delays in getting an ultra

‐

sound appointment might mean having to wait an entire

week longer before a physician is available at the closest

PPINK center, or travelling to the health center where a phy

‐

sician is on duty. Moreover, the new law causes other prob

‐

lems related to delay. Although the informed

‐ consent pro

‐

cess only took approximately fifteen minutes before, after

the enactment of the new law, the process took as long as

seventy

‐ five minutes. This added to the cost of child care,

missed work time, and made it harder to hide visits from

abusive partners.

The district court credited the evidence that the demands

on the PPINK staff trying to accommodate so many addi

‐

tional ultrasound appointments during the period of time

the law was enforced were unsustainable. The additional

quantity of appointments required staff to stay late and took

away resources from the many non

‐ abortion services that

PPINK provides such as cancer screening, well

‐ women

health screening, family planning, and preventative services.

According to PPINK’s CEO, requiring staff to work at this

pace and level of intensity is not workable over the long

term, and ultimately leads to high staff turnover, exacerbat

‐ ing the problem further. R. 24

‐ 1 at 11.

Finally, the district court found that the new regulation

has an impact on victims of domestic violence. The district

court noted that one national study showed that 13.8% of

women who had an abortion had been in an abusive rela

‐ tionship within a year before the abortion. 273 F. Supp. 3d at

1026. Instead of stealing away for a fifteen

‐ minute informed

‐

consent session at a nearby PPINK health center, abused22 No. 17

‐ 1883

women trying to keep their choice confidential have to ar

‐

range to be away for all or most of two days.

The district court also considered the anecdotal evidence

submitted by PPINK about nine women who could not ob

‐

tain an abortion due to the burdens imposed by the new ul

‐

trasound law. The court considered the following narratives

collected by PPINK from women who described their expe

‐

riences as follows:

• The nearest PPINK health center to a woman

seeking an abortion was over an hour away,

and due to the fact that she has two young

children and difficulty with transportation, she

was unable to schedule the two lengthy trips

during the thirteen week, six day timeframe in

which an abortion is available.

• A woman from the Fort Wayne area did not

schedule an abortion because of the two

lengthy trips necessary. She was eleven weeks,

four days pregnant when she contacted

PPINK, but could not miss work twice within

the short timeframe remaining.

• A woman who previously had an abortion at

PPINK called to schedule another, but ulti

‐ mately said she could not schedule one after

she was informed she would have to make two

trips to the PPINK health center in Blooming

‐

ton, Indiana.

• A woman living in a shelter with two young

children decided not to schedule an abortion

appointment because of the transportation andNo. 17

‐ 1883 23

childcare difficulties two appointments would

cause.

• A woman who recently started a new job af

‐

ter a year of unemployment stated that she

could not drive the three

‐ hour roundtrip to a

PPINK health center on two separate occasions

due to the combination of work, childcare, and

transportation expenses, in addition to her

concerns regarding the confidentiality of the

abortion.

• A woman who did not learn she was preg

‐

nant for ten weeks faced a long delay before

she could have her informed

‐ consent appoint

‐

ment that required travel to a PPINK health

center, and by the time of her appointment she

was one day beyond the deadline for an abor

‐

tion.

• A woman from Fort Wayne who had a pre

‐

vious abortion at PPINK called to schedule an

‐

other, but once she was informed that she

would have to make two lengthy trips to a

PPINK health center, she said she could not af

‐

ford to do so and did not schedule an abortion.

• A woman living an hour north of Fort

Wayne who has special needs children de

‐

clined to schedule an abortion after learning

that she would have to make two lengthy trips

for each appointment, as she could not afford

to be away from her children for that long on

two occasions.24 No. 17

‐ 1883

• A woman from Fort Wayne who was ap

‐ proaching the deadline to have an abortion de

‐

clined to schedule an appointment due to the

required travel and risk of missing the dead

‐

line by the time she could schedule both ap

‐ pointments.

273 F. Supp. 3d at 1029–30 (citing R. 24–1 at 16–17; R. 38–1 at

1–2).

Before the district court, and again on appeal, the State

argued that PPINK’s examples were unreliable as they were

passed on to a PPINK staff member and then to the declar

‐

ant without PPINK taking any action to verify the infor

‐

mation. The district court considered the reliability issue but,

noting that a court could base a preliminary injunction on

less formal procedures and less extensive evidence than a

trial on the merits ( citing Dexia Credit Local v. Rogan

, 602 F.3d

879, 885 (7th Cir. 2010)), the district court found the evidence

to be sufficiently reliable for the purpose at hand. The court

reasoned that the reports reflected a plausible, if not likely,

consequence of the new ultrasound law. Moreover, the court

recognized that, as we explore more fully below, the State’s

“ only evidence that the law furthers its interest in promoting

fetal life is from a woman whose testimony was admitted

into evidence through the declaration of her physician.” 273

F. Supp. 3d at 1030 (emphasis in original). In a good

‐ for

‐ the

‐

goose

‐ and

‐ gander way, the district court pointed out that if,

for purposes of the preliminary injunction, the court ignored

all evidence not directly from its source, “the State would be

left without any evidence directly supporting its position.”

Id. The district court’s comparison was apt and its conclu

‐No. 17

‐ 1883 25

sions reasonable. We cannot say that this was an abuse of

discretion to consider the anecdotal evidence on both sides.

The State argued that PPINK could mitigate these bur

‐

dens by making different medical and business decisions,

primarily by outfitting all of its health centers with less ex

‐ pensive ultrasound equipment and by putting more re

‐

sources toward abortion services. 7 PPINK’s director of abor

‐

tion services explained that the $25,000 machine that PPINK

ordinarily purchases comes with an extended warranty, in

‐

cludes planned maintenance, replacement parts, software

updates, support, and a guaranteed 24

‐ hour response time if

there are any problems with the machine. R. 38

‐ 1 at 3–4. It

also integrates with PPINK’s electronic record system which

is critical when the ultrasound and abortion appointment

occur at different health centers. Id. at 4. And, as PPINK

points out, even if it could afford to buy the machines, it

would still be limited by space and personnel. The district

court rejected the State’s mitigation argument, noting that

the “undue burden inquiry does not contemplate re

‐

7 Before the district court, the State also argued that PPINK should ac

‐

cept ultrasounds results from other providers, but has dropped that ar

‐

gument on appeal. The State law requires that the same provider who

performs the ultrasound also engage the patient in the informed

‐ consent

process. The required informed

‐ consent process is very specific and de

‐

tailed and requires that the person providing the information provide

some information that only the abortion provider might have, such as

the name of the physician performing the abortion, the physician’s medi

‐

cal license number, and the emergency phone number where the physi

‐

cian can be reached twenty

‐ four hours a day, seven days a week. Ind. St.

16

‐ 34

‐ 2.1.1(a)(4). The district court found that, given these requirements,

it seems unlikely that an outside provider could comply with the in

‐

formed

‐ consent procedure as dictated by the statute. We agree.26 No. 17

‐ 1883

examining every pre

‐ existing policy or practice of abortion

providers to see if they could further mitigate burdens im

‐ posed by a new abortion regulation.” 273 F. Supp. 3d at

1023. In general, courts do not micromanage an entity’s

business decisions. See Riley v. Elkhart Cmty. Sch.

, 829 F.3d

886, 895 (7th Cir. 2016) (noting that, in the Title VII context,

courts do not “second

‐ guess[] employers’ business judg

‐

ments”). Provided PPINK set forth a reasonable explanation

for purchasing these particular ultrasound machines—and it

has, indeed, done so—the district court was entitled to defer

to PPINK’s justifiable business decisions and consider the

burdens of the new ultrasound law within the context of the

reality that exists for both PPINK in operating its business

and for the patients it serves. We agree with the district

court’s assessment and its deference to PPINK’s reasonable

business decisions. In addition, we note that it also would be

reasonable for PPINK to make decisions about its medical

equipment needs based not only on economic concerns, but

also on its ability to provide the best medical care for its pa

‐

tients, to attract certain medical professionals, for the safety

of its technicians, to prevent malpractice claims, or for any

number of other legitimate reasons.

The same can be said of PPINK’s staffing decisions. The

State thought that PPINK also could mitigate burdens by

training nurse practitioners to interpret ultrasounds. This

training, however is both expensive and requires four weeks

away from clinical work. PPINK rationally could determine

that it was not the best allocation of its resources. The State

argues that the right to an abortion does not insulate PPINK

from making difficult decisions about the allocation of re

‐

sources. That may be true, but neither is it appropriate for an

opposing party or a court to dictate the best use of resourcesNo. 17

‐ 1883 27

for a business, provided its choices are within the range of

reasonableness—but particularly in the case of a non

‐ profit

agency with limited funding seeking to provide the most ef

‐

ficient health care services to a mostly poor population.

The district court credited the attestation by PPINK’s

president and CEO that PPINK was unable to supply each

center with the equipment and staff it needed to provide ul

‐

trasounds. In response to the new law, PPINK did buy one

new ultrasound machine for one of its non

‐ abortion

‐ providing health centers and trained a staff member to use

ultrasound equipment at another, indicating its commitment

to providing as much service as it could despite the burdens

of the new law. The State’s argument about PPINK merely

needing to shift resources to afford the ultrasound machines

is both odd and unworkable. Only 7% of PPINK’s patients

receive abortion services, so in theory PPINK could shift re

‐

sources for the 93% of its other services to abortion services.

It seems illogical for a state with an asserted interested in

protecting fetal life to be encouraging PPINK to shift all of its

resources from other healthcare, such as pregnancy preven

‐

tion and cancer screening, to abortion services. It is unwork

‐

able because, as we noted, neither the State nor the courts

has the authority to rewrite PPINK’s mission and dictate

how it must allocate its limited resources. PPINK operates in

a world where limited health care dollars for mostly poor

women must be allocated in an efficient way, and in a way

that provides the greatest care for the greatest needs.

The fact that courts are bound by the reality in which the

laws operate is reflected in other abortion cases. In Whole

Women’s Health

, the Court found that the requirement that

all abortion facilities meet the standards for ambulatory sur

‐28 No. 17

‐ 1883

gical centers would reduce the number of abortion facilities

in Texas from forty to seven and thus unconstitutionally

burden the right to an abortion. Whole Women’s Health

, 136

S. Ct. at 2301, 2318. The Court looked at the cost a facility

would have to incur to meet the requirements—$1–$3 mil

‐

lion—and assumed that the facilities would close rather than

be able to meet the requirements, despite the fact that each

facility could, in an alternate universe where resources were

unlimited, simply make the changes. Id. at 2318.

Similarly, in Schimel

, this court looked at the burden im

‐ posed by the proposed abortion law requiring physicians

who provide abortion services to have admitting privileges

at a hospital within thirty miles of the abortion clinic.

Planned Parenthood of Wisc., Inc. v. Schimel

, 806 F.3d 908, 918

(7th Cir. 2015). In granting an injunction, we recognized that

the delays caused by the new law might cause some women

to lose the chance to have an abortion within the time period

that Planned Parenthood allowed. No one in that case sug

‐ gested that Planned Parenthood provide later term abor

‐

tions. Id. Instead this court spent most of the opinion exam

‐ ining the reality of what an emergent situation might look

like in the abortion context and how a patient in such a situa

‐

tion might receive care. Id. at 912–16. Courts must consider

the impact of the new ultrasound law based on the reality of

the abortion provider and its patients, not as it could if pro

‐

viders and patients had unlimited resources.

The State’s arguments about mitigating child care bur

‐

dens similarly miss the mark. The State suggests that women

simply could bring along their children to the ultrasound—

most of which are performed transvaginally at these early

stages. See R. 35

‐ 5 at 27. But Planned Parenthood’s policyNo. 17

‐ 1883 29

prohibits children at ultrasound appointments, and with

good reason. One wonders at what age a child could appro

‐ priately sit through such a procedure? A woman undergoing

a transvaginal ultrasound must lie still while the transducer

is inserted into her vagina and used to view the fetus and

her organs. See https://www.healthline.com/health/transvag

inal

‐ ultrasound. She would have no way to soothe a crying

baby or monitor a toddler running through the exam room.

Neither the person performing the ultrasound nor the pa

‐

tient is in a position to monitor the safety of the child in a

medical examination room, and PPINK submitted evidence

of its concerns about the “serious risk of distraction” for the

doctor performing the procedure. R. 35

‐ 5 at 26. Nor would

most women wish to undergo such a procedure with a pre

‐

teen son or daughter in the room, even with, as the State

suggests, a sheet draped over her legs. Like all women, poor

women deserve a level of dignity and choice about the con

‐ fidentiality of their healthcare. Moreover, this is a perplexing

argument from a State that wants women to seriously “re

‐

flect upon compelling evidence of fetal humanity,” and form

a bond with the fetus “while viewing this live, moving im

‐

age of their baby, with arms and legs.” Appellant’s Brief at 2,

4. It seems likely that having children in the room would

significantly decrease the ability for serious reflection in the

bulk of situations.

2. Benefits

Balanced against these substantial burdens, the district

court considered the intended benefits of the new law. As

we just noted, the State wishes to “encourage women to re

‐

flect upon compelling evidence of fetal humanity,” and to

persuade a woman to reconsider her decision to have an30 No. 17

‐ 1883

abortion. Appellant’s Brief at 2, 18, 20, 23. The State argues

that ultrasounds have a unique impact on a pregnant wom

‐

an because they allow her to see her own fetus rather than a

photograph or illustration of a generic fetus, and this, the

State hopes, helps “create a bond that leads them to continue

their pregnancy.” Appellant’s Brief at 4.

The new ultrasound law encourages women to carry

pregnancies to term in two ways, the State argues. First, it

gives them information about their particular fetus and, sec

‐

ond, it gives them time to reflect upon that information be

‐

fore they make their final decision. According to the State,

“A woman offered the chance to view an ultrasound 18

hours before an abortion may well have a different mindset

than a woman who has already made a final decision and

presents herself at the clinic to carry it out.” Appellant’s

Brief at 25. To support its claim that ultrasounds matter, the

State introduced a study demonstrating that for the 7% of

women who seek abortions and have medium to low “deci

‐

sion certainty,” (presumably meaning that they are not very

certain about their choice), those who viewed an ultrasound

image had a 95.2% rate of proceeding with an abortion com

‐ pared to 97.5% rate for women with high decision certainty

who viewed an ultrasound. Mary Gatter et. al. Relationship

Between Ultrasound Viewing and Proceeding to Abortion

, 123

Obstetrics & Gynecology 81, 83 (2014). This evidence, how

‐

ever, is focused on the benefits of an ultrasound and not the

benefits of an ultrasound eighteen hours before an abortion.

The State’s strongest evidence that the eighteen

‐ hour re

‐ quirement provides some benefit, however, came from the

testimony of Dr. Christina Francis, a board

‐ certified obstetri

‐

cian

‐ gynecologist who testified that she had a patient whoNo. 17

‐ 1883 31

would have benefitted from the new law. The patient had a

medication abortion at PPINK in Indianapolis and under

‐

went the required ultrasound that day, as required by the

law at the time. She told Dr. Francis, that she regretted hav

‐ ing the abortion

and feels that an ultrasound waiting period

would have given her more time to consider

her decision and change her mind.

... She un

‐

derwent the ultrasound on the day of her abor

‐

tion, immediately prior to receiving the medi

‐

cation. She chose not to view the ultrasound

image because she felt that if she saw an image

of her baby it would cause her to change her

mind. She told [Dr. Francis] that she did not

want to be persuaded not to abort because she

was already at the clinic, had paid for the abor

‐

tion, and felt pressured by those circumstances

to go through with it. [She] told [Dr. Francis]

that had she undergone the ultrasound the day

before the abortion, she likely would have

viewed the image and she does not think she

would have come back the next day to proceed

with the medication abortion.

R. 35

‐ 1 at 5. This is the State’s strongest evidence because it is

the only evidence that the eighteen

‐ hour waiting period mat

‐

ters for women seeking abortions, as opposed to the ultra

‐

sound itself.

The State also argued that voluntary waiting periods are

common for other procedures where physicians give pa

‐

tients the opportunity to weigh the costs and benefits of var

‐

ious options and think of additional questions or concerns.32 No. 17

‐ 1883

As evidence, the state presented the declaration testimony of

Dr. Francis, who explained her preference to “give patients

time to reflect on the information they have received, weigh

the possible risks and benefits of the procedure, discuss the

procedure with loved ones, and ask questions of the doctor.”

R. 35

‐ 1 at 2–3. She stated that for “life altering” procedures,

she provides informed

‐ consent information one to four

weeks prior to the procedure. R. 35

‐ 1 at 3. The State did not

argue that a waiting period is mandatory for any of these

procedures.

Finally, the State argues that the ultrasound law advanc

‐

es important state interests in the psychological health of

women considering abortion. For this proposition it relied

on a controversial and much maligned (see below) study by

Priscilla K. Coleman which concluded that “quite consistent

‐ ly

... abortion is associated with moderate to highly in

‐

creased risks of psychological problems subsequent to the

procedure.” Priscilla K. Coleman, Abortion and Mental

Health: Quantitative Synthesis and Analysis of Research

Published, 1995

‐ 2009, 199 British Journal of Psychiatry, 180–

86 (2011). Moreover, the State argued, the earlier ultrasound

ensures that a woman does not become psychologically

committed to having an abortion only to arrive for the pro

‐

cedure and learn that she has waited too long.

The district court unequivocally accepted the State’s as

‐

serted interests as legitimate. Indeed, Casey instructs that

“the State has a legitimate interest in promoting the life or

potential life of the unborn.” Casey

, 505 U.S. at 870. And, of

course, no one would argue that protecting maternal psy

‐ chological health is not a legitimate state interest.No. 17

‐ 1883 33

3. Weighing

After this thorough compilation of the burdens and bene

‐

fits, the district court turned its attention to resolving the ul

‐

timate question—whether, after considering the burden the

law imposes on abortion access, together with the benefits

those laws confer, the new ultrasound law has “the effect of

placing a substantial obstacle in the path of a woman’s

choice” to have an abortion. Whole Women’s Health

, 136 S. Ct.

at 2309 (citing Casey

, 505 U.S. at 877). But before the court

could weigh the benefits and burdens, it had to answer two

baseline questions: first, what group of women should the

court consider when weighing the burdens imposed, and

second, on what aspect of the law should the court focus its

benefit and burden weighing analysis—in other words, what

is the relevant question presented by this case. The Court in

Whole Women’s Health made the answer to the first question

clear by explaining that a court must look specifically at

“those women for whom the provision is an actual rather

than an irrelevant restriction.” Id. (citing Casey

, 505 U.S. at

895). In this case, the district court determined that the rele

‐

vant group consisted of low

‐ income women who live a sig

‐

nificant distance from one of the six PPINK health centers

offering informed

‐ consent appointments.

As for the question of which benefits and burdens the

court must weigh, the district court emphasized that the

question it was required to consider was “whether the ultra

‐

sound law provides the asserted benefits as compared to the

prior law. ” 273 F. Supp. 3d at 1031 (emphasis in original) (cit

‐ ing Whole Women’s Health

, 136 S. Ct. at 2311). In other words,

the only relevant burdens and benefits to consider as a court

weighs one against the other are the burdens imposed by the34 No. 17

‐ 1883

requirement to have an ultrasound at least eighteen hours be

‐ fore an abortion, and the benefits of having the ultrasound at

least eighteen hours before the procedure (not the burdens or

benefits of the ultrasound itself). PPINK did not challenge

the requirement that a patient undergo an ultrasound at

some point prior to the abortion. Nor was it challenged

when it was enacted. See Appellant’s Brief at 4. Therefore

the benefits of having an ultrasound at some time prior to an

abortion (without regard to the “eighteen hour prior” re

‐ quirement) are irrelevant. It is the burden of travelling twice

which becomes the obstacle to access.

Having determined the proper focus of the inquiry, the

district court could turn to its ultimate task of determining

whether the burdens of the law’s requirements were “dis

‐ proportionate, in their effect on the right to an abortion”

compared to the benefits that the restrictions are believed to

confer.” Schimel

, 806 F.3d at 919. To determine whether a

burden is undue, the court must “weigh the burdens against

the state’s justification, asking whether and to what extent

the challenged regulation actually advances the state’s inter

‐

ests. If a burden significantly exceeds what is necessary to

advance the state’s interests, it is ‘undue,’” and thus uncon

‐

stitutional. Schimel

, 806 F.3d at 919.

The district court found that the burdens were signifi

‐

cant: additional travel expenses, childcare costs, loss of en

‐

tire days’ wages, risk of losing jobs, and potential danger

from an abusive partner. 273 F. Supp. 3d at 1037. Increased

travel distance, the Whole Women’s Health Court instructed,

constitutes a concrete hardship that can ultimately contrib

‐

ute to the burden being undue. Whole Woman ʹ s Health

, 136

S. Ct. at 2313. See also Schimel

, 806 F.3d at 919 (noting thatNo. 17

‐ 1883 35

the 90

‐ mile, one

‐ way trip from Milwaukee to Chicago might

not cause a significant burden to a person who can afford a

car or train ticket, but was indeed an undue burden for the

large percent of women seeking abortions who live below

and far below the poverty line). These are just the types of

burdens, the district court concluded, that prevent women

from exercising their right to have an abortion.

The funneling of all informed

‐ consent appointments to

the six PPINK health centers with ultrasound equipment

imposed other burdens. It required PPINK to double

‐ book

appointments which increased wait times for appointments

and elongated the duration of those appointments. These

were the kinds of incremental burdens that the Supreme

Court considered in Whole Women’s Health as well, when it

noted that “[t]hose closures meant fewer doctors, longer

waiting times, and increased crowding,” and that those bur

‐

dens, along with increased driving distances were the type

of incremental burdens, which, when taken together ade

‐ quately support an “undue burden” conclusion. Whole Wom

‐

an ʹ s Health

, 136 S. Ct. at 2313.

On the other side of the scale, the district court found

that the State’s many arguments regarding the benefits of the

ultrasound missed the mark by addressing the utility of the

ultrasound itself as opposed to the period of reflection. But

even considering the merits of that data submitted by the

State, the district court noted that the ultrasound effect study

relied upon by the State described the potential impact of

viewing an ultrasound to have a “very small” effect on a po

‐

tential pool of only about 7% of women seeking abortions—

those who had low or medium decision certainty, and no

impact on women with high decision certainty—those who36 No. 17

‐ 1883

make up 93% of women seeking abortions. 273 F. Supp. 3d

at 1032–33 (citing Gatter, Obstetrics & Gynecology, Vol. 123

at 83). And although the study states that women with low

decision certainty who viewed an ultrasound image had a

95.2% rate of proceeding with an abortion compared to

97.5% rate for women with high decision certainty who

viewed an ultrasound, (Gatter, Obstetrics & Gynecology,

Vol. 123 at 83) the State does not tell us how many women

with low decision certainty changed their minds even with

‐

out seeing an ultrasound image. For the ultrasound to have

any impact, the women must actually view the ultrasound,

and only approximately 25% of PPINK patients chose to do

so (We do not know whether that number differs between

low and high decision

‐ certainty patients because the State

presented no evidence on that point.). This means that if

there is any chance that this “very small” impact will suc

‐

ceed it will do so only for the pool of women consisting of

the 7% of abortion seekers with low or medium decision cer

‐ tainty and only on whatever percentage of that 7% who ac

‐ tually choose to also view the ultrasound, but likely only

25% of that 7% or 1.75%. Nor can we tell if these low deci

‐

sion

‐ certainty patients might have changed their minds even

without the ultrasound. In general, the study that both par

‐

ties cite of over 15,000 women seeking abortions at a

Planned Parenthood in Los Angeles demonstrated that most

visits end in abortion—98.8%. Gatter, Obstetrics & Gynecol

‐

ogy, Vol. 123 at 82. For the whole population of women in

that study who viewed an ultrasound, 98.4% had an abor

‐

tion. Id. It seems from the study that increasing gestational

age of the fetus (something that can be determined without

ultrasound), had more to do with the decision not to proceed

to abortion than viewing of an ultrasound. Id. The districtNo. 17

‐ 1883 37

court concluded that if viewing the ultrasound has little to

no impact, then “[i]t is simply not a reasonable assump

‐

tion

... that further time to deliberate on an image that has

nearly no impact at the time, would create a meaningfully

stronger impact after eighteen hours.” 273 F. Supp. 3d at

1034.

We agree with the State that it is entitled to try to per

‐

suade women not to have an abortion even if the impact is

minimal. Nevertheless, in weighing the benefit of the partic

‐

ular measure at issue, a court may consider the minimal pu

‐

tative effects of the State’s action. The more feeble the state’s

asserted interest, “the likelier the burden, even if slight, to be

‘undue’ in the sense of disproportionate or gratuitous.”

Planned Parenthood of Wisconsin, Inc. v. Van Hollen

, 738 F.3d

786, 798 (7th Cir. 2013).

More importantly, even if the ultrasound does influence

a very small percentage of women to alter their decision, all

of that is irrelevant, because, as the district court explained,

“[e]vidence that some women’s decisions as to whether to

have an abortion are impacted by viewing the ultrasound is

not evidence that doing so at least eighteen hours before the

abortion, rather than on the day of the abortion, has any ad

‐

ditional persuasive impact.” 273 F. Supp. 3d at 1032.

The State’s argument that the additional eighteen hours

gives women time for deeper reflection and to absorb infor

‐

mation, actually does address the question at issue in the

case, but its argument is unsupported by anything other

than Dr. Francis’ one anecdote. Moreover, one could just as

easily infer that the impact of viewing the ultrasound image,

for some women, dissipates over the eighteen hours before

the abortion. The State asks us to infer that some women38 No. 17

‐ 1883

who choose not to view the ultrasound do so because they

are under a time pressure and because they have arrived at

the health center having already made up their minds, but

the State offers no evidence for this. Recall that even under

the old law, women who arrived at the health center on the

day of their abortion had already received copious infor

‐

mation from the State designed to alter their decision to

abort, and had plenty of time—at least eighteen hours—to

digest and consider their options while not under an acute

time pressure.

The only relevant evidence the State submitted to sup

‐

port the proposition that the eighteen

‐ hour requirement in

‐

creases a woman’s ability to reflect more seriously on her

decision came from the testimony of Dr. Francis who stated

that one patient reported to her that she might have opted to

view the ultrasound and then might have continued her

pregnancy had she been given the option to view the ultra

‐

sound eighteen hours before her procedure, as opposed to at

the time of the procedure. The district court noted that this

was indeed some evidence that women may change their

minds if they have more time to reflect on the decision, but it

also found this singular example to be exceedingly specula

‐

tive. “She can only say that she ‘likely’ would have viewed

the ultrasound, if it was offered a day earlier” (which cur

‐ rently only about 25% of women do), and “she ‘likely’ would

not have returned for an abortion the next day.” 273 F. Supp.

3d at 1035. The district court, when weighing how much

weight to give this evidence, concluded that this was “far

from compelling evidence that the new ultrasound law

would have the impact desired by the State, and as such, it

must be given diminished weight in the balancing process.”No. 17

‐ 1883 39

Id. We see no reason to disrupt the district court’s vast dis

‐

cretion in weighing this evidence.

Dr. Francis’ other testimony—that some of her pregnant

patients have told her that “viewing an ultrasound image of

their baby caused them to decide not to have an abortion”

(R. 35

‐ 1 at 4)—does not add anything to the consideration of

whether viewing the ultrasound eighteen hours prior to the

abortion alters the calculus in any way.

The State’s argument that doctors commonly use in

‐

formed

‐ consent waiting periods to give patients time to con

‐

sider important medical decisions does come closer to the

relevant question in the case—the benefit of a waiting period

between acquisition of knowledge and a medical procedure

itself. Dr. Francis testified about the importance of giving pa

‐

tients time to reflect, weigh risks and benefits, and think of

questions. See R. 35

‐ 1 at 3. The district court noted, however,

that Dr. Francis does not provide abortion services and

therefore could not attest to the utility of a waiting period

after an informed

‐ consent process preceding an abortion.

The district court instead gave more weight to PPINK’s ar

‐

gument that abortion procedures are different than other

procedures where doctors give information long before a

procedure, because unlike in the context where a doctor is

providing a previously unknown diagnosis to a patient and

then detailing various options, a woman visiting PPINK to

have an abortion knows her diagnosis (she is pregnant), as

well as her options—she may continue the pregnancy or

have an abortion. Moreover, the law already requires that

she be informed of her options and wait eighteen hours until

the procedure. The only issue is whether having the ultra

‐

sound eighteen hours before alters the calculus. Finally,40 No. 17

‐ 1883

there is a qualitative difference between a state

‐ mandated

waiting period, which the State requires only for abortions,

and other optional waiting periods, for all other procedures,

where a doctor and her patient may decide together whether

time for reflection would be optimal or whether, for exam

‐ ple, waiting would cause the patient anxiety, inconvenience,

or deter her from having the desired procedure at all.

Moreover, as the district court discussed, there are many

office procedures that gynecologists might perform immedi

‐ ately after discussing the procedure and asking for consent,

such as colposcopies and LEEP procedures. 273 F. Supp. 3d

at 1034. And there are many times that doctors might need

to perform an emergent procedure immediately after

providing informed consent, or times in which patients

might opt for immediacy even in a non

‐ emergent situation

for the sake of convenience or because they are certain of

their decision. Unlike for a hysterectomy or tubal ligation,

waiting a few weeks for an abortion is not an option because

abortions are not available at PPINK after 13 weeks and six

days post last menstrual period, and the most vigilant wom

‐

an will not know she is pregnant until about four weeks af

‐

ter her last menstrual period. In short, abortions are far more

time sensitive than most other elective procedures.

Ultimately, the district court’s conclusion that the new ul

‐

trasound law posed an undue burden was solidified by the

fact that the State had almost no evidence that the additional

time to reflect advanced its interests. Almost all of the State’s

evidence on the benefits of the new eighteen

‐ hour ultra

‐

sound law focused on the benefits women might receive

from having an ultrasound, and not the benefits from having

to wait eighteen hours after having an ultrasound to obtainNo. 17

‐ 1883 41

the procedure. The district court noted this and therefore

dismissed much of this evidence as irrelevant to the discus

‐

sion at hand. But before the district court did so, it went

above and beyond its duty and thoroughly evaluated the

merits of the evidence nevertheless. For example, the district

court rejected the State’s evidence regarding women’s men

‐

tal health noting that the science behind Dr. Coleman’s stud

‐

ies, described above, had been nearly uniformly rejected by

other experts in the field. 273 F. Supp. 3d at 1036. The district

court chose to credit instead two mental health organizations

that conducted a comprehensive review of studies on mental

health and abortion and concluded that “on the best evi

‐

dence available

... [t]he rates of mental health problems for

women with unwanted pregnancy were the same whether

they had an abortion or gave birth.” R. 38

‐ 3 at 3. A task force

of the American Psychological Association similarly re

‐

viewed studies and concluded that, “the most methodologi

‐ cally sound research indicates that among women who have

a single, legal, first trimester abortion of an unplanned preg

‐

nancy for non

‐ therapeutic reasons, the relative risks of men

‐

tal health problems are not greater than the risks among

women who deliver an unplanned pregnancy.” Id. at 2–3.

That report specifically criticizes Dr. Coleman’s 2002 report

as being “characterized by a number of methodological limi

‐

tations that make it difficult to interpret the results.” Id. at 4.

The district court, using its substantial discretion weighed

the competing evidence and determined that PPINK’s evi

‐

dence was “significantly more persuasive on this issue, es

‐ pecially given that Dr. Coleman’s studies are the subject of

significant criticism.” 273 F. Supp. 3d at 1036. This type of

evidence weighing is well within the district court’s prov

‐42 No. 17

‐ 1883

ince, and we see no reason to disturb its thoroughly rea

‐

soned findings.

More importantly, the court below noted, Dr. Coleman’s

study failed to address the relevant question: whether hav

‐ ing an ultrasound eighteen hours before an abortion leads to

more favorable psychological outcomes. Id. And, as we have

discussed extensively, this was the ultimate question that the

district court had to address.

The district court considered all of the following togeth

‐

er: the fact that over a third of surgical abortions occur with

‐

in three weeks of PPINK’s deadline for performing abor

‐

tions; the difficulty of making two lengthy trips in quick suc

‐

cession; the over

‐ booking of informed

‐ consent appoint

‐

ments; and the fact that physicians only provided abortions

on limited days in each health center. Adding these burdens

together, the district court concluded, “it would be surpris

‐ ing if the new ultrasound law did not prevent a significant

number of low income women from obtaining an abortion.”

273 F. Supp. 3d at 1038. And indeed the evidence provided

by PPINK from nine women who were, in fact, severely

burdened and impeded in their attempts at obtaining an

abortion in the short time that the law was in effect, confirms

this prediction.

The district court did not err by concluding that the ul

‐

trasound law “imposes significant burdens against a near

absence of evidence that the law promotes either of the bene

‐

fits asserted by the State.” Id. at 1039. See Whole Women’s

Health

, 136 S. Ct. at 2318 (striking down the challenged abor

‐

tion restrictions because the law “provides few, if any, health

benefits for women” and “poses a substantial obstacle to

women seeking abortions.”). “A statute that curtails the con

‐No. 17

‐ 1883 43

stitutional right to an abortion

... cannot survive challenge

without evidence that the curtailment is justifiable by refer

‐

ence to the benefits conferred by the statute.” Schimel

, 806

F.3d at 921.

The State would like to simplify the court’s complex bur

‐

den and benefit weighing to a more cookie cutter approach

and have us conclude that Casey paved the way for an al

‐

most per se approval of all reasonable waiting periods. Ap

‐ pellant’s Brief at 20–22, 38. The Supreme Court in Casey up

‐

held a twenty

‐ four hour, informed

‐ consent waiting period

despite the fact patients would need to make two sometimes

lengthy trips in order to obtain an abortion. Casey

, 505 U.S. at

885–87. And we followed suit in A Woman ʹ s Choice

‐ E. Side

Women ʹ s Clinic v. Newman

, 305 F.3d 684, 691 (7th Cir. 2002),

upholding Indiana’s eighteen

‐ hour waiting period after an

in

‐ person informed

‐ consent meeting. But one of the primary

lessons of Whole Women’s Health is that the burden and bene

‐

fit weighing is context

‐ specific. In Whole Women’s Health

, the

court based its conclusions about undue burden on the

280,000 square miles of Texas territory, the number of abor

‐

tion

‐ offering facilities that could operate after the enactment

of the contested law, the number of patients each remaining

facility would have to accommodate (1,200 per month), the

distance women would have to travel to get to a clinic and

the population numbers for women who would have to

travel this far, the rate of deaths and complications from

abortions in Texas, and the cost to clinics of coming into

compliance with the new regulation. Whole Women’s Health,

136 S. Ct. at 2301–03. The Court spent much time discussing

the importance of these facts in assessing the constitutionali

‐

ty of the contested law, noting that a statute valid as to one44 No. 17

‐ 1883

set of facts may be invalid as to another. Id. at 2306 (citing

Nashville, C. & St. L.R. Co. v. Walters, 294 U.S. 405, 415 (1935)).

The Court in Casey noted that “in theory at least, the

waiting period is a reasonable measure to implement the

State’s interest in protecting the life of the unborn,” and

went on to analyze whether such a “waiting period is none

‐

theless invalid because in practice it is a substantial obstacle

to a woman’s choice to terminate her pregnancy.” Casey

, 505

U.S. at 885 (emphasis ours). This was the exact reasoning we

adopted later, in light of Casey

, where we noted that “[w]hile

a twenty

‐ four hour waiting period that requires two trips to

an abortion provider has been found not to impose an undue

burden on Pennsylvania women based on the circumstances

of that state at the time the Court decided Casey, a similar

provision in another state’s abortion statute could well be

found to impose an undue burden on women in that state

depending on the interplay of factors”—factors such as “the

number of physicians who perform abortions, the number of

abortion facilities, the distances women must travel in order

to reach an abortion facility, and the average income of

women seeking abortions.” Karlin v. Foust

, 188 F.3d 446, 485

(7th Cir. 1999). The language in these cases reflects that the

facts and context rule the day when evaluating waiting peri

‐

ods. This is far from being a blanket stamp of approval on

them.

Analyzing the regulation in light of the reality of the facts

in Indiana is precisely what the district court did in this case.

A court cannot assess the law in a world where PPINK has

unlimited resources to open dozens of clinics, each with the

ability to provide ultrasound and abortions along with un

‐

limited access to other health care needs, or in a world whereNo. 17

‐ 1883 45

all women have paid sick days, and reliable child care and

transportation. The court must take the facts as they are pre

‐

sented before it and compare the burdens against the weight

of the evidence of the benefits specific to the proposed law.

Whole Women’s Health

, 136 S. Ct. at 2310. The district court

did just that and concluded that the evidence of benefits was

exceptionally slight if any, and the burden imposed by the

double travel requirement great. As the district court con

‐

cluded, “the new ultrasound law creates significant financial

and other burdens on PPINK and its patients, particularly on

low

‐ income women in Indiana who face lengthy travel to

one of PPINK’s now only six health centers that can offer an

informed

‐ consent appointment. These burdens are clearly

undue when weighed against the almost complete lack of

evidence that the law furthers the State’s asserted justifica

‐

tions of promoting fetal life and women’s mental health out

‐

comes.” 273 F. Supp. 3d at 1043.

The State argues to this court that the district court’s find

‐ ings are clearly erroneous. We cannot agree. Under the clear

error standard we can reverse a district court’s factual find

‐ ings only if “based on the entire record, we are left with the

definite and firm conviction that a mistake has been commit

‐

ted.” United States v. Orillo

, 733 F.3d 241, 244 (7th Cir. 2013).

The district thoroughly addressed each of the burdens and

benefits asserted by the parties and engaged in a painstak

‐ ingly thorough weighing. Its factual findings were not clear

‐ ly erroneous and are entitled to our deference.

C. The remaining preliminary injunction considerations

That conclusion about the likelihood of success on the

merits does not end the inquiry, although it certainly puts

the heaviest weight on the scale. PPINK must also show that46 No. 17

‐ 1883

it is likely to suffer irreparable harm in the absence of pre

‐ liminary relief and that it has no adequate remedy at law.

City of Chicago v. Sessions

, 888 F.3d 272, 282 (7th Cir. 2018). “If

those burdens are met, the court must weigh the harm that

the plaintiff will suffer absent an injunction against the harm

to the defendant from an injunction, and consider whether

an injunction is in the public interest.” Id.

For PPINK and its patients who lose the opportunity to

exercise their constitutional right to an abortion, the irrepa

‐ rability of the harm is clear. Even an extended delay in ob

‐ taining an abortion can cause irreparable harm by “re

‐ sult[ing] in the progression of a pregnancy to a stage at

which an abortion would be less safe, and eventually ille

‐ gal.” Planned Parenthood of Wis.

, 738 F.3d at 796. The evidence

suggests that the new ultrasound law has already prevented

some women from exercising their constitutional rights. It

has caused delay to others. Because we, like the district

court, have concluded that there is no substantial evidence

that the law furthers its stated interest, any harm to the State

is minimal, at worst. And the State certainly has myriad re

‐ maining methods to persuade women to carry a pregnancy

to term in order to promote the State’s interest in promoting

fetal life.

The State argues that PPINK can avoid some of the harm

by expending more resources on abortion services, buying

more ultrasound machines, but again, the court must take

the record as it finds it and not base its finding on what the

facts might look like if the court could devise a different

business or care model for PPINK. See, e.g., Whole Women’s

Health

, 136 S. Ct. at 2318. In any case, PPINK presented evi

‐

dence that it has already shifted resources and tried to miti

‐No. 17

‐ 1883 47

gate harm to the best of its ability. Some of these changes are

unsustainable long term. Others cannot be made at all.

Balanced against the harm to PPINK patients is the

State’s claim of irreparable harm. The State faces the same

harm any State faces when a democratically enacted law is

enjoined. It also claims that it would prevent it from further

‐ ing its goal of promoting fetal life. This we think, is a mini

‐

mal, potentially temporary harm in this case, compared with

the burdens on the women that the district court identified.

This is particularly true when we consider that—even credit

‐ ing the State’s asserted benefit of the law—the potential abil

‐ ity to alter any woman’s decision in a manner that protects

fetal life would be minimal, at best.

As for the public interest, the district court found that

upholding constitutional rights serves an important public

interest and we see no reason to add to or upset this finding.

And because the State had not demonstrated that its interest

would be served by the law, neither could the public’s inter

‐

est.

III.

The State asserts that its reason for this new eighteen

‐

hour ultrasound requirement is to persuade women not to

have an abortion. There is no doubt that this is a legitimate

position for a state to take. But it is also true that women

have the right to choose to have an abortion, albeit with

some limitations. Casey

, 505 U.S. at 846. Women, like all hu

‐

mans, are intellectual creatures with the ability to reason,

consider, ponder, and challenge their own ideas and those of

others. The usual manner in which we seek to persuade is by

rhetoric not barriers. The State certainly is entitled to use48 No. 17

‐ 1883

these rhetorical tools to persuade women not to have an

abortion. It has chosen to do so by requiring an informed

‐

consent process—the required contents of which it has de

‐ signed and mandated—and an ultrasound and fetal heart

beat requirement. It also requires every woman to receive a

brochure about abortion, the contents of which the State con

‐

trols in toto—from how it will present the images of fetuses

to the decisions about which medical risks it includes and

which it omits (for example, the brochure which a woman

takes home and is supposed to ponder for eighteen hours,

does not speak of the risk to the fetus from drugs and alco

‐

hol that a woman may have consumed prior to knowing

about an unplanned pregnancy). Moreover, it states as fact

that “human physical life begins when a human ovum is fer

‐

tilized by a human sperm”—a proposition debated among

scientists, religious leaders, and medical ethicists. The State

has vast power to use the information that it provides to per

‐

suade women not to have an abortion. But the requirement

that women have the ultrasound eighteen hours prior to the

abortion places a large barrier to access without any evi

‐

dence that it serves the intended goal of persuading women

to carry a pregnancy to term. Instead, it appears that its only

effect is to place barriers between a woman who wishes to

exercise her right to an abortion and her ability to do so.

Rhetoric and persuasion are certainly legitimate methods for

a state to assert its preference, but it cannot force compliance

with its otherwise legitimate views by erecting barriers to

abortion without evidence that those barriers serve the bene

‐

fit the state intended. “Until and unless Roe v. Wade is over

‐

ruled by the Supreme Court, a statute likely to restrict access

to abortion with no offsetting medical benefit cannot be held

to be within the enacting state’s constitutional authority.”No. 17

‐ 1883 49

Schimel

, 806 F.3d at 916. In light of the evidence of substantial

burdens imposed by the law and without evidence that the

additional eighteen hours following an ultrasound has any

legitimate persuasive effect on decision

‐ making, the law

constitutes an undue burden on those seeking an abortion

without any known benefits to balance it. The opinion of the

district court is AFFIRMED in all respects.50 No. 17

‐ 1883

K ANNE

, Circuit Judge

, concurring in the judgment. Our

decision today is compelled by long

‐ standing Supreme

Court precedent. See Roe v. Wade

, 410 U.S. 113 (1973); Planned

Parenthood of Se. Pa. v. Casey

, 505 U.S. 833 (1992).

The State’s reason for the new 18

‐ hour ultrasound re

‐ quirement is to persuade women not to have an abortion. As

the opinion notes, “[t]here is no doubt that this is a legiti

‐

mate position for a state to take.” Majority Op. at 47. This, of

course, is weighed against the fact that “women have the

right to choose to have an abortion, albeit with some limita

‐

tions.” Id.

In this case two evidentiary factors lead me to conclude

that the 18

‐ hour requirement imposes an undue burden on a

woman’s right to choose, which requires affirming the deci

‐

sion of the district court. The first factor is the additional

travel necessitated by the availability of only six ultrasound

imaging sites located in Indiana at PPINK health centers. 

The second factor is that the State offered little evidence to

show that an 18

‐ hour wait following an ultrasound would

persuade those seeking an abortion to preserve fetal life.

Based on the foregoing factors, I agree that, in the context

presented by this appeal, Ind. Code § 16

‐ 34

‐ 2

‐ 1.1(a)(5)—as

written—constitutes an undue burden on women seeking an

abortion.

This concurrence extends to the final judgment set forth

by my esteemed colleague, Judge Rovner, but does not en

‐

 On appeal, the State did not pursue the argument that PPINK should

accept ultrasound results from the many other Indiana providers of ul

‐

trasound imaging throughout the State. See Majority Op. at 24, n.6.No. 17

‐ 1883 51

dorse the propriety of the ancillary findings of the district

court.