By Melinda Young
Here are some of the chief reproductive healthcare challenges that have occurred since the U.S. Supreme Court’s decision to overturn Roe v. Wade with the June 2022 decision in Dobbs v. Jackson Women’s Health Organization:
Reproductive healthcare training is challenging for many OB/GYN residents and other physicians.
Abortion bans have had a large impact on training for OB/GYN medical students and residents. “A significant number of our OB/GYN training programs are in banned states now,” says Cynthia Chuang, MD, MSc, a professor of medicine and public health sciences and co-director of the Penn State Center for Women’s Health Research at Penn State College of Medicine in Hershey, PA. Chuang authored a paper for internists about abortion care and procedures.1
“Over the course of the last two years, the number of medical students applying for OB/GYN training programs in banned states has gone down, and that will significantly affect our workforce,” Chuang says. “We also know that trainees often stay in the state where they trained to establish practice, and it will get to the point where there is no one there to provide [abortion] care.”
This trend of abortion-providing physicians avoiding states with abortion bans has already begun. Another smaller trend is that physician trainees across all specialties are not selecting abortion-ban states in the numbers they did before the Dobbs decision, she adds. “Maybe they don’t want to live where it is a banned state,” Chuang says.
“There will be repercussions down the road with the workforce because there is going to be a decline in people who want to train in these states,” she adds. “I have colleagues working in those states, and they have a really hard time recruiting physicians to work there.”
This trend applies to physicians regardless of their gender because they have daughters and wives, and they say they cannot practice in a banned state, Chuang explains. “If this is a long-lasting effect of Dobbs, and it could have long-term repercussions for our healthcare workforce,” she adds.
It also will negatively affect maternity care in the nation, as evidenced by an increase in hospitals closing their labor and delivery units. Also, there is an increase in cases — in abortion-ban states — of pregnant patients who have to take a helicopter to an out-of-state hospital, or who are delivering babies at home, or who are suffering without care from ectopic pregnancies and miscarriages in hospitals. Their doctors fear acting because they may face potential arrest. Also, some hospitals have no obstetric staff who can provide standard miscarriage and ectopic pregnancy care.2
For example, in May 2024, the Association of American Medical Colleges (AAMC) published an analysis, showing that fewer new graduates of U.S. medical schools applied to residency programs in states that banned or restricted abortion access than applied to residency programs in states where abortion is legal.3
There was a small decrease of 72 MD senior applicants in the United States in the 2024 cycle, but the total number of applications submitted by all U.S. MD seniors decreased by more than 100,000. This represented a “disproportionate decrease in applicants to programs in states with abortion bans.”3
More women are being targeted by local law enforcement for investigation and arrest because of actions they took while pregnant.
At least 210 women faced criminal charges because of their pregnancies in the first year post-Dobbs, according to a new report by Pregnancy Justice.4 That was the largest single-year number of pregnancy prosecutions since researchers began tracking the cases, the report says.4
Alabama was the most aggressive in prosecuting women because of their pregnancies, accounting for 104 — about half — of the prosecutions. Oklahoma was next with 68, and South Carolina had 10 prosecutions. Ohio, Mississippi, and Texas also prosecuted people based on their alleged actions during or shortly after pregnancy.4
They charged the mostly low-income defendants with child abuse, neglect, endangerment, criminal homicide, drug charges, abuse of a corpse, and miscellaneous crimes.4 Most of the charges alleged substance use during pregnancy, and five cases had allegations about abortions. Of the 210 cases, 121 involved hospitals and medical professionals reporting the women.4
The report notes that as the United States’ dire maternal health crisis continues with high numbers of people dying from pregnancy each year and access to quality healthcare decreasing, these prosecutions show that states would rather invest in judicial punishment than increasing access to OB/GYNs and maternity departments.4 “In 15 cases, prosecutors or police argued that pregnant people’s failure to obtain prenatal care was evidence of a crime,” the report notes.4
It is likely the legal landscape for patients and providers will become worse until abortion bans end. A new report in The Intercept describes how a Jackson, MS, post office investigated an envelope with pills, labeled “AntiPreg Kit.” They were made in India for a self-managed medication abortion, and a postal worker had reported this hot pink envelope to the police because they saw someone put pills in it and suspected these were abortion pills.5 AntiPreg and other brands can be ordered on the website of Plan C, and one dose can cost $38, including shipping, The Intercept reports.5
In the event of a Republican presidency, this could be the scenario across the nation. Vice presidential candidate J.D. Vance signed a letter to the U.S. Department of Justice in January 2023, asking Attorney General Merrick Garland to resurrect the Comstock Act to ban abortion nationwide, starting with mail-order abortion medication operations. If he becomes vice president, he will not need to sign a letter to make this de facto national abortion ban happen.6
People seeking abortion care and calling in to a reproductive health line need to know what their risks are as they decide whether, how, and where to obtain an abortion, says Angel M. Foster, DPhil, MD, AM, a professor in the faculty of health sciences at the University of Ottawa in Ottawa, Ontario, Canada. “We refer patients to the reproductive health line IfWhenHow.org, which provides information about legal risks,” Foster adds.
Abortion access has shifted dramatically to self-managed medication abortion, often using telehealth services.
Crises can lead to opportunities, and this was true with the COVID-19 pandemic and the Dobbs decision. Both crises led to the Biden Administration increasing access to abortion medication via telehealth, which resulted in telehealth abortion increasing five-fold from 2022 to 2024, from 4% of abortions to 19%.7
“In many ways, these findings document positive changes for abortion access. The role of virtual-only providers and online pharmacies in abortion provision is relatively new,” says Terri-Ann Thompson, PhD, senior research scientist at Ibis Reproductive Health in Cambridge, MA. The Food and Drug Administration (FDA) only revised restrictions to make direct-to-patient telehealth medication abortion provision possible in 2020, she notes.
“Our results show the critical role that online pharmacies are playing in medication abortion care,” Thompson says. “However, despite the literature showing that pharmacy dispensing is associated with safe use of medication, a reduction in healthcare costs, and potentially preventing adverse drug events, the FDA’s remaining restrictions on pharmacy dispensing persists.” Those restrictions need to be removed to allow more people to receive abortion care as soon as they need it, she adds.
The U.S. Supreme Court can end most abortions nationwide with decisions the court left dangling in their last session.
In the Supreme Court’s 2023-2024 session, the court unanimously rejected a lawsuit that challenged the FDA’s decision in approving and expanding access to mifepristone, the abortion drug it approved 20-plus years earlier. But the decision left a door open for future groups to sue against access to the medication because the rejection was based on a technicality — that the plaintiffs did not have standing to challenge approval and regulation of the drug. (See the July 2024 issue of Contraceptive Technology Update.) If another group, whom the court determines does have standing, brings a similar lawsuit, telehealth mifepristone could be in jeopardy again.
There is another threat to abortion access that is more immediate, and that is the 1873 Comstock Act, which bans the mailing and receiving of obscene materials, including articles involving abortion. Even under a Harris presidency, the Comstock Act could be a threat because some anti-abortion group could cite it in a federal lawsuit that makes its way to the Supreme Court. Under any Republican presidency, it is likely the Comstock Act would be enforced at the federal level and even could be used to shut down all abortions nationwide. If a new administration decides to interpret the act the same way anti-abortion groups are interpreting it, then it would mean that abortion providers cannot receive instruments, supplies, and medication mailed by suppliers. It would end abortion care in any regulated healthcare setting nationwide.8
“Misuse of the Comstock Act is a different concern,” Thompson says. “Some are presenting an inaccurate interpretation of the act — suggesting that materials for a lawful abortion cannot be mailed via a common carrier.”
If litigation moves forward based on this interpretation, then it will remove access for thousands of individuals who have no other options for this type of care because of abortion bans in their states, she adds. “It also will remove access to those for whom direct-to-patient provision of medication abortion is the preferred abortion method,” Thompson says.
The solution would be for a democratic-leaning Congress to pass a law to repeal the Comstock Act and remove that threat for future generations. U.S. Sens. Tammy Duckworth (D-IL) and Tina Smith (D-MN) and additional senate Democrats introduced the Stop Comstock Act bill in June 2024, to repeal the 151-year-old law. The bill was referred to the Committee on the Judiciary and the Committee on Ways and Means but has not yet come up for a vote.9
References
- Chuang CH, Horvath S. Abortion. Ann Intern Med. 2024;177(10):ITC145-ITC160.
- Stolberg SG. As abortion laws drive obstetricians from red states, maternity care suffers. New York Times. Sept. 6, 2023. https://www.nytimes.com/2023/09/06/us/politics/abortion-obstetricians-maternity-care.html
- Orgera K, Grover A. States with abortion bans see continued decrease in U.S. MD senior residency applicants. AAMC Research and Action Institute. May 9, 2024. https://www.aamcresearchinstitute.org/our-work/data-snapshot/post-dobbs-2024
- Bach WA, Wasilczuk MK. Pregnancy as a crime: A preliminary report on the first year after Dobbs. Pregnancy Justice. September 2024. https://www.pregnancyjusticeus.org/wp-content/uploads/2024/09/Pregnancy-as-a-Crime.pdf
- Nathan D. Undelivered. Drug-sniffing police dogs are intercepting abortion pills in the mail. The Intercept. Oct. 16, 2024. https://theintercept.com/2024/10/16/abortion-pills-mail-usps/
- Diamond D, Kornfield M. Vance urged DOJ to enforce Comstock Act, crack down on abortion pills. Washington Post. July 17, 2024. https://www.washingtonpost.com/health/2024/07/17/jd-vance-abortion-comstock-vice-presidential-nominee/
- Nadworny E. Despite state bans, abortions nationwide are up, driven by telehealth. NPR. May 14, 2024. https://www.npr.org/sections/health-shots/2024/05/14/1251086997/abortion-increase-research-wecount-telehealth
- Winny A. The threat to abortion rights you haven’t heard of. Johns Hopkins Bloomberg School of Public Health. May 31, 2024. https://publichealth.jhu.edu/2024/how-the-comstock-act-threatens-abortion-rights
- H.R. 8796 – Stop Comstock Act. Congress.gov. June 21, 2024. https://www.congress.gov/bill/118th-congress/house-bill/8796
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
