The judges ruled 4-3 that the law — passed by the Republican-led legislature in 2023 — is constitutional, reversing a temporary injunction put in place by a district court last year while allowing the ongoing litigation at that level to proceed. The statute has limited exceptions for rape and incest or if a woman’s life is in danger.

The outcome again disrupts the landscape of reproductive health in Iowa, with most women now having to travel outside the state to terminate a pregnancy. It follows two closely watched decisions this month from the U.S. Supreme Court, both more favorable to abortion supporters, and signals how much access remains in flux across the country.

Eighteen states now ban all or most abortions, affecting more than 1 in 3 American women ages 15 to 44, a Washington Post analysis shows. The issue is sure to be key in the fall elections, with voters considering abortion rights ballot measures in several states, including Florida, Colorado and South Dakota. President Biden is counting on abortion to keep female voters in his camp, potentially proving the critical difference for his reelection in November.

In a statement Friday morning, Iowa Gov. Kim Reynolds (R) said that “there is no right more sacred than life” and that she was “glad” her state’s high court had upheld the ban. She said her administration would “continue to develop policies that encourage strong families, which includes promoting adoption and protecting in vitro fertilization.”

The ACLU of Iowa called the court’s decision “a devastating blow to Iowans’ access to essential health care,” while the head of the Iowa Democratic Party took aim at the GOP, saying in a statement that “Republicans went too far with this abortion ban.” About 4,000 women in the state sought abortions in each of the past two years.

“Today, Iowa women have been stripped of reproductive rights that they have maintained for more than 50 years,” chair Rita Hart said. “It’s obvious Kim Reynolds and Iowa Republicans do not trust women to make their own decisions regarding their own medical care or for doctors to use their best judgment while treating their patients.”

Abortion providers in Iowa have been doing contingency planning for months in advance of the court’s ruling, according to Ruth Richardson, president of Planned Parenthood North Central States, which has three Iowa facilities that provide abortion care. The organization didn’t schedule any abortions for Friday to protect patients in case of an adverse ruling, she said. It already has expanded locations in nearby states — doubling the number of patient beds in Omaha and moving to a larger site in Mankato, Minn. — to assist women coming from Iowa, she said.

“We wanted to make sure that no matter what happened we will continue to meet the needs of Iowans that need access to abortion care,” Richardson said.

Under Iowa court rules, it will take at least 21 days for the case to be sent back to the district court, the ACLU noted. Abortion will remain legal in the state until then.

During the court’s oral arguments on April 11, the justices quizzed lawyers from both sides on earlier rulings that first expanded and then limited the scope of abortion protections in the state and whether this case should have been sent back to a lower court for further arguments and review.

The law will limit the procedure to a time frame in which many women don’t yet know they are pregnant. The exceptions will only apply if a sexual assault is reported to law enforcement or a health provider within 45 days for rape and 145 days for incest. Medical exceptions include a fetal abnormality “incompatible with life” or if the pregnancy endangers the woman’s life.

Across the country, abortion remains a contentious issue at both the federal and state level.

In an opinion Thursday, the U.S. Supreme Court permitted physicians in Idaho to resume performing emergency abortions while litigation continues in the lower courts. That ruling, however, does not resolve whether a long-standing federal law compels doctors nationwide to carry out the procedure when they believe a woman’s health is in danger.

And two weeks ago, the court unanimously preserved access to mifepristone, the medication now used in more than 60 percent of U.S. abortions.

Those decisions followed a pair of seismic state judicial rulings this spring. Florida’s Supreme Court held that abortion rights are not protected by that state’s constitution, paving the way for one of the country’s strictest bans to take effect May 1. Arizona’s Supreme Court also revived an 1864 law prohibiting the procedure except to save a mother’s life — and punishing providers with jail time — but the legislature and governor, acting amid a firestorm of condemnation, repealed the law before it could take effect this summer.

Iowa’s legislature passed an abortion ban in 2018 that was permanently blocked by the courts. Reynolds, a Republican staunchly opposed to abortion, brought lawmakers into a special session last summer to pass a second six-week ban. That was quickly enjoined by a district court judge, though the rulemaking process was allowed to move forward.

The rules subsequently adopted by the state Board of Medicine have been criticized by legal experts for being too vague and lacking specifics about when doctors can step in to save the life of a pregnant patient or how providers who violate the law would be punished.

The issue remains a deeply divisive one in the state, although a majority of Iowans say abortion should be legal in most cases. A Des Moines Register/Mediacom Iowa Poll released last year found that 61 percent of residents believe it should be legal in most or all cases, with 35 percent opposed.

On Saturday, hundreds of abortion opponents rallied at the Capitol in Des Moines in advance of the expected ruling.