EXECUTIVE SUMMARY
Reproductive health providers are experiencing seismic changes in where and how they practice in the United States in the wake of the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision.
- The nation will need more advanced practice providers and primary care providers to fill reproductive healthcare gaps where there are shortages of OB/GYNs.
- There is a huge ripple effect caused by state laws banning abortion care and hospital lawyers declining such care — even to save the patient’s health and life.
- A Tennessee woman spent six hours in an ambulance to reach a state where she could obtain a life-saving abortion.
Months after Roe v. Wade was overturned, reproductive healthcare providers and patients are experiencing enormous — and sometimes disastrous — changes.
For instance, state abortion bans are expected to affect where OB/GYNs and other reproductive health clinicians choose to study and practice. These bans also will affect how and whether medical students and residents are fully educated in contraceptive care and counseling, abortion care, miscarriage care, ectopic pregnancy treatment, and high-risk pregnancy care.1,2
The U.S. Supreme Court’s decision in the Dobbs v. Jackson Women’s Health Organization case could result in large swaths of the United States losing access to OB/GYNs and reproductive healthcare in their own and neighboring counties and towns.
This problem could escalate quickly. “As we have already seen — even with a few months of the Dobbs decision — it does not just affect abortion care, it affects so much of healthcare,” says Julia Strasser, DrPH, MPH, director of the Jacobs Institute of Women’s Health and an assistant professor of health policy and management at George Washington University’s Milken Institute School of Public Health.
The reproductive care workforce must expand beyond OB/GYNs to meet the need in coming years. Advanced practice providers (APPs) and primary care providers (PCPs) will need to fill some gaps.
“Especially in these [maternity care desert] areas, increased training for primary care providers will be important,” says Ellen Schenk, MPP, a research associate at the Fitzhugh Mullan Institute for Health Workforce Equity in the department of health policy and management at the Milken Institute School of Public Health. “We need to think about the health workforce beyond OB/GYN and how we can train and make sure family medicine and pediatrics and the entire primary care provider workforce is prepared to provide these services and how it could help with deserts of OB/GYNs.”
General internists can help women obtain contraceptive care and other reproductive health services in the Dobbs era, says Rachel S. Casas, MD, EdM, an associate professor of medicine in the division of general internal medicine at Penn State Milton S. Hershey Medical Center.
“As general internists, we’re very well trained in being able to discuss risks and benefits of medication with our patients, including contraception,” Casas says. (For more information, see the story in this issue on PCPs and workforce changes in the post-Dobbs era.)
Advanced practice providers also can help fill gaps where people have little or no access to reproductive health providers. “It’s really important in those areas that may not have family medicine clinicians providing those services,” Schenk says.
One issue is a likely decline in medical training of abortion care. Abortion procedures also are necessary to care for pregnant women with miscarriages and life-threatening pregnancy problems. In abortion-ban states, women already are denied abortions to save their health or lives, according to news reports.3
“You’ve seen the news and anecdotal reports of people who are not receiving potentially life-saving care for miscarriage, even if it was very much a wanted or planned pregnancy, because doctors have been forbidden or are afraid of providing what is seen as an abortion service,” Strasser says. “That is one huge ripple effect.”
When physicians are told by their health system administrators and lawyers that they cannot risk providing abortion care unless the fetus is dead or the woman is about to die, they experience moral distress. This could lead to reproductive health providers leaving states where abortion bans threaten their ability to provide patients with the best care. This already appears to be happening.
For example, an obstetrician who treats high-risk patients in Chattanooga, TN, saw a pregnant patient with rising blood pressure and a fetus diagnosed with genetic abnormalities. The fetus would not survive, and the physician thought the woman was at risk of pre-eclampsia, seizures, and death. The only effective medical treatment was an abortion. But Tennessee’s trigger ban on all abortions at six weeks forced the woman’s doctor to choose between treating her and risking arrest and facing up to 15 years in prison, or not treating her. The physician sent the woman on a six-hour ambulance ride to North Carolina for the abortion. When the patient arrived, she already showed signs of kidney failure. The patient survived, and the obstetrician decided to move to Denver, where she could practice without fear of prosecution for providing life-saving abortion care.3
The long-term effect could be worse because fewer clinicians may know how to provide abortion care for miscarriages. An estimated 48% of medical students will receive their education in a state with significant abortion restrictions or bans, according to a new study.1 Those students may have little or no clinical exposure to abortion procedures. Another repercussion is that women medical students will have their own access to abortions and contraception restricted in many of those states. This may lead to fewer people applying to medical schools in abortion-ban states.
Researchers focused on how the Dobbs decision would affect medical students’ decisions about their medical education, says Alyssa B. Stephenson-Famy, MD, lead study author and associate professor in the department of obstetrics and gynecology at the University of Washington.
“For the undifferentiated medical student, how will Dobbs impact their education and care choices leading up to medical care?” she asks. “That was our focus.”
Stephenson-Famy and colleagues were concerned abortion bans would affect delivery of clinical care and leave medical students, interns, and residents with less education, training, and information about counseling on abortion, genetic disorders, fetal anomalies, miscarriages, and more.
“We were concerned the decision would have an impact on our foundational, basic science education that has to do with contraceptive pharmacology, emergency contraception, and medication abortion,” Stephenson-Famy explains. “Places [without] access to safe abortion have higher maternal mortality rates.”
This likely will be the result of states where there are few or no physicians willing and capable of performing the procedure on women who are suffering a life-threatening miscarriage. (For more information, see the related story in the February 2022 issue of Contraceptive Technology Update.)
Reproductive health providers are left with no good choices. They either will need to act against institutional policy and/or state law and provide ethical medical care at the risk of job loss, arrest, and prison time, or they will risk losing patients whose lives and health they could have saved.
Soon, they may even face similar moral dilemmas when patients ask for emergency contraception or long-acting reversible contraception (LARC) — both of which may end up on the chopping block in at least some states.
All these factors make abortion-ban states hazardous places for reproductive health providers. “We have heard some things about people who are unsure about whether or not they want to stay in Texas or accept a position here,” says Kari White, PhD, MPH, lead investigator of the Texas Policy Evaluation Project and an associate professor at the University of Texas at Austin in Steve Hicks School of Social Work.
“People have unplanned pregnancies or planned pregnancies, where they will need medical care to manage a miscarriage, ectopic pregnancy, or other complications that may develop,” White says. “When the healthcare team and setting and laws in the state do not permit clinicians to provide the standard of care out of fear of legal repercussions, I think people should be concerned about that.”
Ohio’s six-week ban has been blocked by courts, unblocked, and blocked again. Reproductive health providers have had to navigate extremely difficult situations. This has created ethical dilemmas.
“OB/GYNs do feel constricted in their ability to practice care in accordance with practical ethical guidelines,” says Hillary J. Gyuras, MA, a research associate in public health at The Ohio State University. Gyuras’ study is part of the Ohio Policy Evaluation Network, which received a grant to conduct research as part of an effort to expand reproductive health services in Ohio and neighboring states. “My paper focuses on how the laws restrict training and restrict the ability to maintain skills to abortion provision. Ohio abortion laws restrict OB/GYNs, students, and residents from safely providing abortion care.”
Hospital physicians in the study’s focus groups said the institutional and state law restrictions left them believing they could not practice medical care that would save patients’ lives and health. They found it strange and frustrating.4
“It definitely contributes to moral distress,” Gyuras says. (See story in this issue on pregnancy care in Texas and Ohio after abortion bans.)
Among providers interviewed, one resident told researchers that she might choose to leave the state. Another person chose to leave after residency because she was restrained from providing care.
“The residents and medical students felt the laws prevented them from having adequate opportunity to provide abortion care,” Gyuras adds. “Our participants expressed a lot of frustration with the laws.”
REFERENCES
- Stephenson-Famy A, Sonn T, Baecher-Lind L, et al. The Dobbs decision and undergraduate medical education: The unintended consequences and strategies to optimize reproductive health and a competent workforce for the future. Acad Med 2022;Nov 8. doi: 10.1097/ACM.0000000000005083. [Online ahead of print].
- Strasser J, Schenk E, Dewhurst E, Chen C. Changes in the clinical workforce providing contraception and abortion care in the US, 2019-2021. JAMA Netw Open 2022;5:e2239657.
- Kusisto L. Doctors struggle with navigating abortion bans in medical emergencies. The Wall Street Journal. Oct. 13, 2022.
- Field MP, Gyuras H, Bessett D, et al. Ohio abortion regulations and ethical dilemmas for obstetricians-gynecologists. Obstet Gynecol 2022;140:253-261.
Months after Roe v. Wade was overturned, reproductive healthcare providers and patients are experiencing enormous — and sometimes disastrous — changes. For instance, state abortion bans are expected to affect where OB/GYNs and other reproductive health clinicians choose to study and practice. These bans also will affect how and whether medical students and residents are fully educated in contraceptive care and counseling, abortion care, miscarriage care, ectopic pregnancy treatment, and high-risk pregnancy care.
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