Kylie Cooper, MD, did not want to leave Idaho.
The maternal-fetal medicine specialist had great colleagues and deep connections to her patients, many of whom she’d helped through high-risk pregnancies. Her kids, 6 and 9, loved their school, their friends, and their neighbors.
But after the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization ended the federal right to abortion — and her state enacted a near-total ban on the procedure — her life changed dramatically.
“My husband and I would talk about this every day. It was consuming us,” says Cooper. “What if I lost my license? What would happen to our kids if I went to jail? What about my guilt if I didn’t help a sick patient to my fullest ability? It was a nightmare.”
“I didn’t feel I could remain a health care provider in a place where I couldn’t help a patient sitting right in front of me,” says Cooper, who now lives in Minnesota. “It was unbearable.”
The historic June 2022 Dobbs decision is roiling the waters for obstetricians-gynecologists (OB-GYNs) like Cooper and those considering the specialty. Many say the ruling has interfered in the physician-provider relationship, undercut their ability to provide evidence-based care, and put them in legal peril. Such setbacks are concerning, experts say, partly because they may spur OB-GYNs — who often provide sorely needed general medical care — to move or leave the field entirely.
“It was consuming us. What if I lost my license? What would happen to our kids if I went to jail? What about my guilt if I didn’t help a sick patient to my fullest ability?”
Kylie Cooper, MD
Already, Dobbs has had major impacts.
Many OB-GYNs — 64%, according to a recent national survey — believe the ruling has worsened maternal mortality, and more than half worry about the field’s ability to attract future providers. In states that ban abortions, 40% of OB-GYNs say they’ve felt constrained in their ability to provide care during pregnancy-related medical emergencies.
The field already faced major challenges before Dobbs. For one, maternal deaths have increased significantly, up 40% between 2020 and 2021. Those deaths also disproportionately impact people of color, with rates three times higher for Black patients than White patients.
In addition, the workforce has been experiencing worrisome shortfalls, especially in certain geographic regions. An estimated 2.2 million U.S. women live in “OB-GYN deserts,” and 4.7 million more live in areas with limited access.
Now, experts worry about fresh strains on OB-GYNs, who often bear low pay and high malpractice insurance fees compared with many other specialties, as well as the stress of late-night hospital runs.
“There is an element of burnout,” says Verda Hicks, MD, president of the American College of Obstetricians and Gynecologists (ACOG). “Many OB-GYNS were feeling this even before COVID-19, but the pandemic certainly exacerbated the issue. As more labor and delivery units close, or more OB-GYNS are forced to leave their communities or the field altogether, those who remain see an increased demand for their services. Keeping up with that demand can become overwhelming.”
“We are seeing more of this now that the Dobbs decision has forced some OB-GYNS out of restrictive states,” she adds. “OB-GYNS experience moral injury when they are prevented from providing the expert care that they are trained to provide. This contributes to burnout too.”
A new landscape for OB-GYNs
The effects of abortion-related restrictions on some OB-GYNs are huge, experts say.
Among them is a confusing tangle of legal demands and restrictions.
“Doctors are trying to apply legal wording that is not clinical to clinical situations,” says Cooper. “How can I know when someone is close enough to death that it’s okay to help them? What if I wait too long and then face a malpractice suit?”
ACOG’s Hicks highlights some concerning outcomes. “OB-GYNs have found themselves having to delay care to consult with attorneys or wait until a patient’s status became unstable to intervene,” she says. She points to a recent report from the University of California, San Francisco, describing preventable harms to patients. Among them are patients whose water broke in the second trimester and who, because they could not terminate their pregnancy, developed dangerous infections.
Meanwhile, institutions are working to support providers, taking steps like putting lawyers on call to answer time-sensitive questions. At Duke Health in North Carolina, leaders pivoted quickly in the face of a new law dramatically limiting where abortions could be performed.
“The law went into effect on a Saturday, and on Monday we were ready to open a replacement clinic inside the hospital,” says Brittany Davidson, MD, a Duke associate professor of obstetrics and gynecology. “That took a lot of work by a lot of people.”
Providers also feel weighed down by mounds of abortion-related paperwork and counseling requirements.
In North Carolina, abortion patients must hear and initial some 20 consent statements, for example. Davidson finds one particularly dismaying. “It says the patient can sue me later if they feel I’ve coerced or misled them into having an abortion. As a physician who takes an oath to do no harm, that feels like a punch to the gut.”
“OB-GYNs have found themselves having to delay care to consult with attorneys or wait until a patient’s status became unstable to intervene.”
Verda Hicks, MD
President, American College of Obstetricians and Gynecologists
Such stresses are leading some providers to relocate — or simply retire. That’s concerning, experts say, because more than half of OB-GYNs are 55 or older, just a few years away from when providers in the field start to retire.
And it looks like replacing those leaving could be tough in some regions. According to AMN Healthcare, a major physician staffing service, 63% of surveyed OB-GYNs said they would not likely take a position in a restrictive state.
“Like medical schools and teaching hospitals in other states with severe restrictions on abortion, we are seeing some of our colleagues move where abortion access is more widely available,” says Shelby Dickison, MD, an OB-GYN at Washington University Physicians in St. Louis. “I worry who will care for the next generation when our staff is gone.”
Medical students on the move
It’s still unclear how the Dobbs decision will affect the professional paths of medical students, but some clues have begun to emerge.
For one, students seem reluctant to pursue residencies in restrictive states. That could exacerbate shortages in certain regions because residents tend to stay where they train.
An April AAMC data snapshot found that the number of U.S. MD senior applicants to programs in states with abortion bans dropped 11% from 2022 to 2023 — twice the decrease in states without restrictions.
“Actual interest in these states could be even lower,” says Atul Grover, MD, PhD, executive director of the AAMC Research and Action Institute and an author of that snapshot. “Students may think, ‘I’d rather match in a restrictive state than risk not matching at all, so I’ll apply more broadly,’ but they ultimately would prefer a program in a less restrictive state.”
Meanwhile, a survey of third- and fourth-year medical students suggests a greater possible post-Dobbs impact. Nearly 60% of respondents said they were unlikely to apply to programs in states that restrict abortion.
Experts point to several possible reasons for this reluctance. High on the list is a desire to receive the fullest possible OB-GYN training.
“The technique used for abortion is the same technique for miscarriages and other medical situations. The more repetition and practice you have, the better trained you are,” says Ariana Traub, a third-year student at Emory School of Medicine in Atlanta who co-authored the study.
Traub points to another concern: “Medical students are also patients, and they are thinking about access to reproductive care for themselves.” And OB-GYN is a field that tends to attract women: In 2021, 86% of residents and fellows in the specialty identified as female.
But beyond a possible maldistribution of future OB-GYNs, experts also worry whether Dobbs will deter students from entering the field entirely.
The AAMC data snapshot indicates a greater drop among applicants to OB-GYN residencies than to almost all other fields. “It’s too soon to tell whether this is a trend, but we ought to keep an eye on it,” says Grover.
Grover also is concerned about the possible impact of ACOG’s recent decision to launch its own residency application platform in 2024. “I worry that this will complicate the process for students in various ways. For example, those applying to more than one specialty will now need to use both this and the Electronic Residency Application Service®,” he says.
On her end, Dickison hopes the new platform will simplify the demanding work necessary to identify appropriate candidates. As for whether it will affect students’ interest in the field, she’s unsure. “I can only hope that students choose a field not based on the application process but on what sparks their passion,” she says.
When it comes to Dobbs, Traub says students fall into two categories. Some want to avoid the political and legal morass of the field, but others have become even more motivated. “For some, it now feels like a calling,” she says.
The realm of residencies
Residency programs in restrictive states are throwing themselves into recruiting applicants and ensuring that trainees get the education they need.
“Dobbs is the most common question I hear, and it takes time away from my ability to talk about other aspects of our program,” says Dickison. Already, she’s seen a 10% drop in residency applications and a 15% drop in applicants for fellowships.
Meanwhile, Dickison and others say they haven’t seen the flipside – antiabortion residents who are now attracted to their program. That may be partly because trainees with religious or moral objections could always opt out of abortion training, even pre-Dobbs.
While addressing recruiting concerns, programs are also working to ensure that they provide the clinical experience in performing abortions required by the Accreditation Council for Graduate Medical Education.
In some cases, that means sending trainees out of state. At Indiana University School of Medicine in Indianapolis, OB-GYN resident Jenifer Akinduro, MD, MS, says her program has been actively seeking out-of-state options in case it fails to have the requisite number of abortion procedures for training.
This is no simple matter, she notes. “Residents need to go through the challenging steps of getting a license in another state. They will also have to travel several hours each way, possibly a few times per week for several weeks. This is hard for residents who already work notoriously long hours.” At other programs that aren’t in commuting distance of less-restrictive states, residents instead have had to relocate for several weeks.
ACOG has now created a curriculum to help with the altered training landscape. Released on August 14, it offers self-paced modules on such topics as abortion counseling. A key goal, according to ACOG, is allowing residents who must travel to hit the ground running once they arrive at their new site.
“Dobbs is the most common question I hear, and it takes time away from my ability to talk about other aspects of our [residency] program.”
Shelby Dickison, MD
Washington University Physicians
Programs are also focusing on providing emotional support to trainees in a field known to be intense even before the Dobbs decision.
“We may need to induce labor for babies who are highly desired but have lethal anomalies. People are sobbing when their baby is born dead,” says Akinduro. “Providers are trying to give care compassionately in a very difficult situation.”
At Washington University, Dickison is bolstering her trainees through support groups and other efforts, including increased connection with faculty. “We want to validate their feelings and let them know we’re feeling that way too.”
On her end, Cooper worries about the strain on the peers she left behind in Idaho — and about where OB-GYN as a specialty is headed more generally.
“I worry about the worsening shortages and health disparities, and that this will deepen the maternal mortality crisis we are facing in this country.” Still, she says, “I am continually inspired by colleagues in restrictive states who embody the steadfast commitment to protect their patients as best they can.”
She says she refuses to despair about her chosen field. “Like I tell my patients facing pregnancy complications, it’s important to be realistic and be prepared for what the outcomes ultimately may be,” she says. “But that doesn’t mean we give up hope.”