Legislative battles over abortion could intensify this year, with both state and federal lawmakers eyeing additional restrictions on access to the procedure.

And ob.gyns. are finding themselves in the middle once again, with some opposing legislative interference in the physician-patient relationship and others supporting increased regulation of abortion providers.

Just days after the start of the 114th Congress, lawmakers introduced H.R. 36 , the Pain-Capable Unborn Child Protection Act, a bill to ban abortion after 20 weeks’ gestation, citing the existence of fetal pain at that point in development. The bill includes exceptions when an abortion is necessary to save the life of a pregnant woman, or in cases of rape or incest.

TAnd while most state legislatures are just gearing up, experts expect to see significant activity on abortion again this year.

Over the last 4 years, state governments have enacted 231 laws limiting access to abortion, with 26 new laws being passed in 2014, according to an analysis by the Guttmacher Institute.

In 2014, Oklahoma added a requirement that abortion counseling include information on the availability of perinatal hospice when a woman is seeking an abortion because of a fetal abnormality. In Alabama, lawmakers extended the waiting period between counseling and obtaining an abortion from 24 to 48 hours. Meanwhile, Mississippi lawmakers banned abortion at 18 weeks post fertilization.

his year will likely be more active than 2014, said Elizabeth Nash , the senior state issues associate at the Guttmacher Institute, since some state legislatures that had been actively targeting abortion access, such as Texas, did not meet last year, and others had shortened sessions.

In addition, more Republican governors and state legislators are taking office in 2015. Republicans now control both legislative chambers and the governor’s office in 23 states. Debate around H.R. 36 also could spur activity at the state level, she said.

For those states that do pursue abortion legislation in 2015, Ms. Nash said she expects them to build on existing restrictions, such as extending the waiting period between mandated counseling and an abortion.

“States will look at existing restrictions and try to make them more burdensome,” she said.

The movement toward increasing barriers to abortion access has some physicians crying foul.

Dr. Nancy L. Stanwood , the section chief for family planning at Yale University in New Haven, Conn., and the board chair of Physicians for Reproductive Health, said many of these proposals claim to be aimed at making abortion safer, but are really a “wolf in sheep’s clothing” because they delay necessary care, jeopardizing safety.

“As a general rule, all of these restrictions do interfere with the doctor-patient relationship,” she said. “I think it has chilling effects on the entire profession.”

Further, some proposals, such as mandates that physicians use outdated protocols for medical abortions, are contrary to medical evidence, Dr. Stanwood said.

H.R. 36 is one proposal that’s not evidence based, according to Dr. Hal C. Lawrence , executive vice president and CEO of the American Congress of Obstetricians and Gynecologists. There’s no evidence, despite a fair amount of literature, to indicate that a fetus can feel pain at that time, he said.

And the actual number of abortions performed after 20 weeks is very low – less than 1% nationally. These typically involve serious medical complications where the termination of the pregnancy is necessary to save the mother’s life, Dr. Lawrence said. “I don’t think we want to take that therapeutic option away from physicians.”

ACOG has been campaigning against the idea of “legislative interference” for the past few years and enlisting physicians from other specialties in the effort. The American Medical Association, for one, has been vocal about its opposition to “governmental intrusions” into the patient-physician relationship and has called on lawmakers to stay out of decisions about what constitutes medically necessary treatment.

“The ability of physicians to provide appropriate treatment options and have open, honest, confidential communications with their patients is an essential value that must be protected,” said Dr. Robert M. Wah , an ob.gyn. and AMA president.

Dr. Lisa M. Hollier, an ob.gyn. in Houston, said she feels the impact of that intrusion firsthand when she’s with a patient.

“My patients come to me, trusting that I will be completely honest with them, open with them, and counsel them fairly regardless of my personal beliefs on a particular topic,” Dr. Hollier said. “When we have legislatures intruding into that very personal moment between a woman and me, it brings in a third party, and she no longer has the complete confidence that I can tell her everything.”

Texas, in particular, has been a battleground when it comes to abortion access. A 2013 Texas law that requires the state’s abortion clinics to adhere to construction, equipment, and staffing standards similar to those of ambulatory surgery centers is currently being challenged in federal appeals court.

The stakes are high in this case, Dr. Hollier said, because if the law is upheld, many facilities won’t be able to meet the new standards, forcing women to travel longer and spend money on lodging, child care, and missed time at work.

“Functionally, what it does is really limit the patient’s opportunity to get access to the full range of reproductive health services,” she said.

But not all physicians see the increasing regulation of abortion services as a problem. Dr. Gene Rudd , an ob.gyn. and senior vice president of the Christian Medical & Dental Associations, said it’s part of the necessary regulation of medical practice, in the same way that the government ensures that only competent surgeons can perform an appendectomy, he said.

“The claim that there’s interference is a smoke screen,” he said.

What makes the abortion situation unusual and different, he said, is that lawmakers and physicians aren’t dealing with an appendix, but an “early life,” Dr. Rudd said. The issue of how early in that life the government should offer legal protections is a societal issue, he added, and lawmakers have every right to define it, with input from experts on all sides.

Dr. Rudd, who supports H.R. 36, said he expects that the abortion battle will continue in state houses and courthouses around the country until there is some cultural consensus around the issue.

“I think it’s going to be an ongoing issue,” he said.

mschneider@frontlinemedcom.com @maryellenny