A 14-year-old girl arrived at Angela Dempsey-Fanning’s, MD, MPH, South Carolina clinic just one day after the state’s anti-abortion law would have allowed her to terminate a pregnancy in instances of rape or incest.
Dempsey, an ob/gyn in Charleston, had to inform the teenager, a victim of incest, that she could not legally provide abortion care, so the girl and her mother decided to seek treatment in a different state.
When I interact with patients in these situations and must deny my care to them, I carry the emotional and mental burden for weeks.
“I couldn’t shake the sense that so many principles of medical ethics were being violated in denying care to her,” said Dempsey, who is also president of the Society of Family Planning, a nonprofit that advocates for abortion access. “When I interact with patients in these situations…I carry the emotional and mental burden for weeks.”
South Carolina is one of 16 states to put in place severe abortion restrictions in the wake of the US Supreme Court ruling in June 2022 on the Dobbs v. Jackson Women’s Health Organization case that overturned Roe v. Wade.
The outcome is an “occupational crisis” for many ob/gyns like Dempsey who practice in states where abortion is restricted or banned, according to a study recently published in the JAMA Network Open.
Public discourse on the Dobbs v. Jackson rulinghas mostly centered on the impact to patients, according to Mara Buchbinder, PhD, professor and vice chair in the Department of Social Medicine at University of North Carolina Chapel Hill School of Medicine, and a co-author of the study.
“We were interested in what the impacts would be for the obstetric workforce as well,” she said.
In 2022 and 2023, Buchbinder and her colleagues interviewed 54 ob/gyns practicing in 13 states where abortion had become illegal with limited exceptions, including Texas, West Virginia, and South Dakota.
Clinicians who participated in the study described instances in which the state restrictions on abortion forced them to delay what they deemed to be medically necessary care until a patient faced severe complications or even death. More than 90% reported moral distress concerning situations where legal constraints prevented them or their colleagues from following clinical standards.
“You have somebody hemorrhaging with an intrauterine pregnancy with a heartbeat…I [didn’t yet] have legal coverage for that, but there’s only so many times you can transfuse somebody and they’re begging for their life before you say, ‘This is unconscionable,'” one clinician reported to researchers.
Another clinician said, “Is a 5% risk of death enough? Does it take 20%? Does it take 50%? What is enough legally?”
This month, the US Department of Health and Human Services announced a new team to ensure hospitals in all states comply the Emergency Medical Treatment and Labor Act, which, according to the Biden administration, includes emergency abortions. Still, some hospitals may not have clear policies that define pregnancy-related emergencies, making it challenging for clinicians to feel protected in clinically complex situations.
The study also highlighted aiding and abetting clauses, which prevent ob/gyns from providing referrals for abortions or discussing the option with patients. Participants described the limitations as undermining their medical expertise.
“Some of the harm that is done to these ob/gyns is not only from the laws themselves, but from their own institutions,” Buchbinder said. “Hospitals have to decide, ‘what does this law mean and how are we going to put it to practice here?”
Angela Hawkins, MD, a hospitalist practicing in Oklahoma, encountered a patient who was experiencing an obvious miscarriage. But because the situation could not yet be established as life-threatening, Hawkins felt that she could not intervene.
“There are things I know are straightforward and I would’ve handled them completely differently in the past,” Hawkins said, adding that she needed to seek reassurance from her hospital employer that she would not face legal ramifications if she provided care.
“It’s frustrating to know that this is medicine and I can’t practice it without calling legal and ethics in the middle of the night,” said Hawkins, who is also chair of the Oklahoma section of the American College of Obstetrics and Gynecology.
Still, more than half of Oklahoma’s 77 counties are considered maternity care deserts, meaning they have little to no obstetric services available for pregnant patients. Hawkins recently completed her own survey of practicing ob/gyns in the state. In soon-to-be published research, almost 60% of the 63 respondents reported thinking about leaving or were planning to leave the state to practice in areas that are less restrictive.
“That’s very concerning to the ob/gyns that are left,” she said. “I feel like, if everyone leaves, who is left to take care of the patients?”
The study in JAMA Network Open also highlighted that 11% of participants had moved their practices to less restrictive states with stronger abortion protections.
In addition to losing existing clinicians, the laws have made it difficult for medical centers to recruit new ones, according to Kavita Shah Arora, MD, MBE, MS, director for Division of General Obstetrics, Gynecology, and Midwifery at the University of North Carolina at Chapel Hill, and a co-author of the study. North Carolina enacted a new law in July 2023 that reduced the time allowed for an abortion from 20 weeks to 12 weeks under most circumstances.
“Our department faces new challenges in recruitment and retention being in a restrictive state that we haven’t had to deal with before,” Arora said. “It’s impacting how medical students choose which residency programs to apply to.”
Ob/gyns may not be the only clinicians who feel the effect of laws restricting abortion, according to Deborah Nucatola, MD, chief medical officer of Planned Parenthood Great Northwest, Hawai’i, Alaska, Indiana, Kentucky.
Patients who live in areas with limited access to obstetrics services often present to urgent care facilities or emergency departments for medical care that are staffed with family, internal medicine and emergency physicians, Nucatola said.
“I don’t want anyone by any means to think this is isolated to one specialty,” Nucatola, who was not involved with the study, said “It’s going to affect everyone who cares for these patients; you lose the ability to use your medical knowledge and then have to navigate this legal restriction that doesn’t correlate with anything that happens in medicine.”
Dempsey’s 14-year-old patient did eventually receive abortion care outside of South Carolina. Dempsey said that she and her colleagues have spent hours coordinating for patients to receive care in a different state. Then, a patient and their family must come up with the money for travel and any missed work to get to another clinician working where abortion is legal.
Despite this, she said, “You are left still feeling as though you abandoned this patient in many practical ways.”
“I know I weigh the decision about my future practice almost daily, wondering how long I can stay and keep fighting for patients in an environment ripe with fear, worry, and an overriding sense of injustice,” Dempsey said.
The study authors and experts quoted in the story report no relevant disclosures.
Lara Salahi is a freelance writer living in Boston.