Abstract
Keywords
History of abortion in the United States (US)
The termination of pregnancy has been a consistent component of societal dynamics since ancient times and has been targeted in the US since 1857. The newly formed American Medical Association (AMA) excluded women and Black people from membership. They aimed to regulate services provided by women, targeting midwives providing abortion services, by introducing the concept that life begins at conception rather than at quickening. 1 Subsequent anti-abortion laws, aiming to prosecute providers for performing abortions, drove the practice underground into less-skilled providers, increasing maternal morbidity and mortality.
The women's rights movement in the 1960s gave momentum to pro-choice activism and the landmark US Supreme Court ruling of 22 January 1973, in Roe v. Wade ruled that women had a constitutional right to privacy, encompassing a woman's decision to terminate a pregnancy. This broadly paved the way for the right of a pregnant person to undergo an abortion until viability as determined by the abortion doctor, and the right to abortion after viability for health reasons was defined broadly to include psychological well-being. This basic right to abortion survived for almost 50 years, despite many challenges, including other prominent cases such as Planned Parenthood v. Casey (1992) that tightened the definition of “undue burden” for women seeking abortion; the Hyde Amendment (1980) that continues to prevent government programs from funding abortions; and the Global Gag Rule (1984) which prohibited international organizations from receiving US funding if they “provide, advocate for, or refer to abortion services” even with their own funds.
In June 2022, access to comprehensive reproductive healthcare changed dramatically in the US with the Dobbs v. Jackson Women's Health Organization ruling. This ruling overturned women's constitutional right to abortion, and now allows individual states to set legislation regarding the legality of abortion and reproductive healthcare. While some states have chosen to protect access to and the availability of abortion care, many states have chosen to place extreme restrictions and total bans on abortion-related services. 2 The impacts of this decision have been extensive, affecting (1) the lives and clinical care of pregnant people; (2) the practice by medical providers, medical training, and conflicts they face with legal demands versus evidence-based care; and (3) the influences of America emboldening an increasingly anti-abortion rhetoric on the global healthcare practices/resources. Here we outline the experience of a physician navigating the post-Dobbs landscape of reproductive healthcare in the US.
Personal perspective
As an obstetrician and gynecologist (OB/GYN) with fellowship training in Complex Family Planning (CFP), I have dedicated my career to the provision of comprehensive reproductive healthcare. The CFP fellowship “provides post-graduate OB/GYNs with additional training in abortion and contraception and opportunities to establish leadership in clinical care, research, and medical education.” 3 My goals were to perform complex cases, to serve as a trusted consultant, and to develop and advocate for evidence-based policies at the institutional, state, and national levels. However, upon completion of my fellowship training in June 2023 in New York, the landscape was drastically different than I had anticipated. New York has historically been supportive of abortion as essential healthcare and requires abortion coverage in private, Medicaid, and ACA marketplace insurance. 2 While I understood that most states would not be as protective as New York, I hoped to find a position in a location that was not severely restrictive. A recent study found that a significant number of OB/GYN trainees indicated that the Dobbs decision changed their geographical practice preferences and/or their fellowship plans. 4 I signed on with an academic institution in North Carolina in January 2023 with the plans to begin working in July 2023. At the time, North Carolina was one of the few states in the South allowing for elective termination until the 20th week of pregnancy. North Carolina had become a referral site for neighboring states such as Georgia, Tennessee, Alabama, and South Carolina. I was eager to provide evidence-based care to individuals who traveled substantial distances and was excited to participate in the training of medical students, residents, and fellows. However, in May 2023, this limit was reduced to 12 weeks by the North Carolina legislature to take effect on 1st July. This felt like a devasting blow, not only for me, but also for the patients who would now have to traverse even more obstacles to obtain essential healthcare.
Transitioning to practice in a restrictive state has been eye-opening. Now, in addition to my standard counseling and care, I am required to complete a consent form 72 hours prior to any procedural or medical abortion with few exceptions. One of the elements of the consent form that struck me the most was the portion that states “I understand that I have a private right of action to sue the qualified physician performing the abortion if I feel I have been coerced or misled prior to having an abortion.” 5 I have never considered inviting a patient to take legal action against me in any other facet of my profession. Despite striving to provide evidence-based and patient-centered care, two fundamental aspects of the practice of medicine, I now regularly pause to ensure that my care is legally or more so, politically defendable.
Due to the lower volume of cases after the restriction, some of the higher-level medical trainees are traveling out of state to obtain training in second-trimester abortions. The strain that these restrictions have placed on medical education is palpable. Prior to Dobbs, almost 50% of OB/GYN residency programs offered routine abortion training. However, post-Dobbs, 14% lost the ability to provide routine in-state abortion training. 6 When considering CFP Fellowship, 5 of 30 programs in the US are in states where an abortion ban has been introduced, and given the volatility of many state legislatures, other programs may be at risk of losing abortion access. Like me, many CFP graduates desired to practice in academic environments, as well as, in underserved locations. However, with over two-thirds of the states in the US having some level of restricted access to abortion, the job market is limited. 7
I, like many other abortion providers in restricted states, travel to provide abortion care to maintain my skills and training and to provide care to those who need it. I have chosen to travel rather than leave North Carolina because I do not want to abandon my community of patients who desperately need accessible reproductive care. Witnessing the struggles of those I care about in states with stringent laws has been a heart-wrenching reminder of the public health crisis unfolding before us. Misinformation about state abortion laws is common, and people's views on abortion, shaped by their identities, values, and experiences, extend beyond simple “pro-life” or “pro-choice” labels, reflecting complex nuances. 8 States like Kansas, Colorado, New Mexico, and Virginia, where abortion is less restricted, have seen an increase in volume as they are situated in abortion care deserts with limited access to clinics and providers for hundreds of miles. Post-Dobbs, ∼ 33.3% of reproductive-age females live in a census tract over 1 hour from an abortion facility compared with 14.6.% in the pre-Dobbs period. 9 It is important to underscore that the “sanctity of life” encompasses not only from conception to birth but also infancy, childhood, and beyond. The new “life” requires sustained support from parents, community, and government programs. States with restrictive abortion laws often lack better outcomes in prenatal care, low birth weight percentages, infant mortality, and immunization rates for children. 10
The discourse on abortion laws in the US is not just an abstract debate; it's a lived reality, a collection of individual stories that, when woven together, reveal the depth of our collective struggle for dignity, autonomy, and justice. As we move forward, may we do so with the understanding that at the heart of every law, every protest, and every court decision, there are people, with their own stories, hopes, and dreams, all deserving of respect and empathy. Discussions surrounding reproductive rights must include sexual health education in schools and equitable and easy access to contraceptives if we want to decrease rates of abortions. Mutual respect and accountability in matters of reproductive health should equally involve men, with attention to topics such as male contraception and shared parental responsibilities. It's a bold voyage, fraught with challenges, but illuminated by the beacon of hope for a more equitable and compassionate society.
