Abortion providers in northern Maine spend a lot of time in the car.

Every other weekday, nurse practitioner Christina Theriault and clinic administrator Cassidy Jarvis drive an hour and 15 minutes from Fort Kent to Presque Isle, toggling between the two farthest-flung abortion clinics in Maine, the most rural state in the country. They travel on Route 161, a two-lane highway, closed in on both sides by dense forest. To pass the time, they count the number of moose they see on the side of the road.

Their current record is 14.

The lone two staffers at either outpost, Theriault and Jarvis work for Maine Family Planning (MFP), an independent network of 18 reproductive health care clinics, providing birth control, primary care, STD screenings and abortion to women across mostly rural parts of the state. Of the 20 clinics that perform abortions in Maine, 18 are operated by MFP.

Like Planned Parenthood, MFP announced its decision last week to withdraw from Title X, a federal law that provides funding for birth control services, rather than comply with the Trump administration’s new regulations. Under the “gag rule,” issued by the Department of Health and Human Services earlier this year, Title X recipients are now prohibited from referring a patient to an abortion provider or mentioning abortion at all.

Title X was MFP’s single largest source of funding, said Cait Vaughan, MFP’s community organizer. Over 27 percent of the organization’s annual budget came from Title X funds.

While much of the media attention around the rule has focused on Planned Parenthood, a large national organization is far less vulnerable than an independent network of clinics like MFP, said Vaughan. Maine Family Planning and other rural, “indie” clinics lack both a steady stream of patients and the donation war chest of an organization like Planned Parenthood, said Emily Nestler, an attorney with the Center for Reproductive Rights who is representing MFP in a complaint against the government: As many as 15 of MFP’s clinics could close as a direct result, she said, creating what experts call a “contraceptive desert.”

“These clinics don’t have anywhere near the resources they need to keep their doors open,” said Nestler. “Maine Family Planning is an independent provider serving very rural, low-income communities, which means they are already operating on a shoestring."

Only 4,000 people live in Fort Kent, a pro-Trump, majority Catholic stronghold that straddles the Canadian border. Potato farming is the largest industry: Kids there still get two weeks off school at the end of September to help with the harvest. Presque Isle is larger, but still relatively small, with a population of 9,000. The next most populated town — Bangor, population 32,000 — is two and a half hours away.

Theriault and Jarvis shuttle between the two clinics because neither has enough patients to stay open five days a week. On a particularly busy day, Theriault will see between six and eight people. She’s tried to grow the patient base, she said, but it’s hard. Since the area is so religious, the clinics have to keep a low-profile. There was one nurse at a college in Presque Isle who used to refer students for birth control and primary care, but stopped suddenly a few years ago, Theriault said, when she found out that MFP was performing abortions.

“That was a very big blow to us,” said Theriault. “With such a high turnover rate, now none of the college students know that we’re here.”

The majority of patients in Fort Kent and Presque Isle can’t afford to pay full-price for treatment. They are hairdressers, waitresses, bartenders and nail technicians, said Theriault, working for small businesses that don’t offer health insurance. Some are high school students who, according to Theriault, “could never let their parents know they’re here.”

MFP charges on a sliding scale — the less you make, the less you pay — using specialized grants and Title X funds to subsidize the rest. Some clients are only asked to make a small donation. Without Title X funding, Jarvis, who handles payment at the clinics, expects they’ll soon have to start charging patients more. Many won’t be able to pay.

Lovely Jourdain, a 23-year-old student at the University of Maine at Fort Kent, came to MFP to get an intrauterine device (IUD). Juggling school and a part-time job as a nurse’s aide, she said she would never have been able to afford the full price of the procedure: $500. After explaining her situation to Jarvis, she only had to pay $100.

“I’m so grateful for that money because I didn’t have to choose between getting sustainable birth control and paying my rent,” said Jourdain, who now works as an intern at MFP. “If you can’t afford something that is so vital to you, like birth control, it’s like you don’t have any control over your life.”

It wasn’t easy for MFP to turn down Title X funding, said Nestler. When the Trump administration released the final version of the new rule, in March, the organization spent a lot of time debating its next steps.

“It was clearly a lose-lose situation,” said Nestler. If organization leaders accepted the funding, they wouldn’t be able to honestly discuss a patient’s options; If they didn’t, they knew clinic closures were likely.

When MFP decided to pull out, Theriault was “completely on board.”

“As a nurse practitioner, the first thing they teach you is about informed consent. You have to educate a person on the risks and benefits of every single thing,” she said.

Maine Family Planning and Planned Parenthood both withdrew from Title X on Aug. 19, the government deadline for organizations to formally agree to the new rules, along with the majority of “indies” affiliated with the Abortion Care Network, the largest association of independent abortion clinics in the country.

But MFP will face challenges Planned Parenthood won’t, said Vaughan.

“We don’t have the name recognition of Planned Parenthood, or the deep pockets,” she said. “Whenever this administration does something terrible with abortion, or when the state abortion bans have come out … everyone starts giving to Planned Parenthood.”

It can be frustrating, Vaughan said, to see Maine locals set up fundraising campaigns for Planned Parenthood on Facebook, especially now, when MFP urgently needs donations. Even though MFP has a much larger presence in Maine than Planned Parenthood, Vaughan said, “people don’t know we’re here.”

“We don’t have that big team of communications staff, or the big field staff, or a national organization behind us, providing all that clout.”

Since the new rule came out, MFP has been doing everything they can to raise money from private donors, Vaughan said. She’s hopeful the state legislature might be able to help make up the difference, but MFP likely won’t know about that until May.

“For the next year,” she said, pausing. “We’re just, things are very uncertain.”

The clinics in the most rural areas are the ones most likely to close, Vaughan said. But those are also the most essential to keep open. If the clinics at Fort Kent and Presque Isle were to close their doors, women would have to drive four hours to get an abortion — longer, Theriault said, if you get stuck behind a moose or a tractor.

“This loss of funding will put our clinics out of business, and it will happen in the places that can least afford to have it happen… all those places where there was already so little access to begin with,” said Julie Jenkins, a nurse practitioner at a MFP clinic in Belfast, a coastal town with a population of 6,600. “That’s really what this whole thing is about.”

For now, Maine Family Planning will be operating as usual. Most patients have no idea that anything has changed.

Until someone tells them to stop, Theriault and Jarvis will continue their biweekly carpool, shuttling their one ultrasound machine back and forth.

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