Comment: Year after Dobbs, women’s health care and women suffering

By Lisa Jarvis / Bloomberg Opinion

It’s been a year since the U.S. Supreme Court decided Dobbs v. Jackson, overturning Roe v. Wade and allowing states to ban abortion. The damaging effect on health care is becoming ever clearer: Abortion can’t simply be excised from medical treatment without reducing the quality of other forms of care.

Physicians are increasingly wary of the ever-shifting rules of engagement and a political climate that is hostile to their expertise. Some are being forced to compromise the care of their patients. Some are daunted by living and working in places where their own bodily autonomy is at risk. This isn’t what they signed up for when they went to medical school.

The severe abortion restrictions in effect in 14 states allow exceptions to save the life of the pregnant woman. But that means women in medical distress, many with wanted but dangerous pregnancies, have been forced to wait for medical care until the law considers their lives sufficiently at risk. They sit at home or even in the parking lot of a hospital, scared or in pain, vomiting or passing clots of blood, and waiting for things to get even worse.

“It makes their care more dangerous,” says Jonas Swartz, an assistant professor of obstetrics and gynecology at Duke Health in North Carolina who has seen a number of patients barred from getting timely care in their home states. It’s surely only a matter of time before a woman dies.

Early data highlight the risk. One small study that looked at maternal and infant outcomes at two Texas hospitals in the wake of the state’s abortion ban found that morbidity doubled when care was put off until an emergency. The 28 women in the study got infections, hemorrhaged and required blood transfusions. One ended up in the ICU. Only one of the infants survived, and that baby was still hospitalized at the time the data were published.

On the other side of those horrifying tales are physicians forced to defy their training. When Dobbs came down, Leilah Zahedi-Spung was working as a high-risk obstetrician in Chattanooga, Tenn., which initially had a trigger law that threatened physicians with prosecution for providing an abortion. “I would be arrested and charged with a Class A felony and then have to prove to a jury that what I did was to save someone’s life,” Zahedi-Spung says. “It was really terrifying.”

The law that ultimately went into effect in August 2022 walked back that so-called “affirmative defense” stance in favor of a physician’s “reasonable medical judgment,” but didn’t assuage her fear that a prosecutor and a jury could second-guess her judgment.

And things are getting worse, especially in the South. In the past, some of Zahedi-Spung’s patients might have been sent to North Carolina, where Swartz could have coordinated care for anyone up to 20 weeks along in pregnancy. (Over the last year, he estimates that at times as many as half of his patients were from out of state.) But last month, the state’s Republican-dominated legislature pushed through a 12-week ban, complicating Swartz’s ability to accept some of those patients. He and other doctors in North Carolina are now trying to figure out how to comply with the law, which takes effect on July 1. It’s “worse health care for my patients, no matter how you cut it,” he says.

The legal risks are driving some OB-GYNs out of states with bans. When an opportunity came up to work in Colorado, which has become a haven for abortion care, Zahedi-Spung left Tennessee. “I was worried I was going to have to make a choice between my well-being and the life of a human being,” she says. “That is never how I ever wanted to practice medicine.”

Every health care provider I spoke with over the last month told me about physicians in their network who, like Zahedi-Spung, had left or were on the cusp of leaving a state with strict abortion laws. In March, a hospital in Idaho closed its labor and delivery unit, blaming in part the political climate that was making it difficult to retain and attract staff. The trend is still nascent, making it hard to put numbers on the magnitude of the effect. But early data suggests anyone who leaves will be hard to replace.

In November 2022, AMN Healthcare, the largest physician-staffing service in the U.S., conducted an internal survey of OB-GYNs to understand how bans might affect its recruitment efforts. In data provided to Bloomberg Opinion, the firm said that 63 percent of the 584 people surveyed — and 77 percent of female OB-GYNs, and 78 percent of OB-GYNs aged 44 or younger — said they would be “unlikely” or “very unlikely” to consider a position in a state banning or severely restricting abortion access.

“Our conclusion is that the Dobbs v. Jackson decision is likely to limit the ability of abortion banning or restrictive states to recruit OB-GYNs, particularly their ability to recruit younger and female OG-GYNs, who represent the future of the OB-GYN workforce,” AMN Healthcare said in an emailed statement.

Those preferences are already starting to affect where physicians are choosing to train. The Association of American Medical Colleges analyzed data from this year’s residency match program, the process by which new doctors are assigned to a hospital for advanced training, and found a 10 percent dip in the number of OB-GYNs who applied for residency in states with complete abortion bans.

That’s terrible news for the state of reproductive health. Especially because the states with the strictest abortion laws also have the most gruesome track record on maternal mortality.

But the impact will go far beyond reproductive health. Consider that many doctors are making decisions about where to work during the years when they are likely to be building their own families. They don’t want to risk getting pregnant in a state that would limit their access to care. Gabriel Bosslet, an associate professor of clinical medicine at Indiana University’s School of Medicine, is particularly worried about the fate of specialties that already are having trouble attracting doctors – areas like infectious diseases or endocrinology.

And doctors might simply avoid those states out of concern that lawmakers are making it too difficult to practice medicine without political interference. The consequences can be serious even when they are acting within the confines of the law. The case of Indiana OB-GYN Caitlin Bernard, who was recently reprimanded by the state’s medical board after she spoke publicly about providing an abortion to a 10-year old rape survivor, is a chilling example.

It’s hard to imagine that Bernard’s experience would be the only time a doctor is sanctioned for simply doing her job; and the next time, the consequences could be worse.

Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.