This article appears in the October 2022 issue of The American Prospect magazine. Subscribe here.
When Jody Steinauer was growing up in the ’80s in Nebraska, Roe v. Wade had been decided less than a decade earlier. The important women in Steinauer’s family, especially her mother, made sure to express to her that reproductive care was essential to the life of a woman and that abortion was a universal right.
As Steinauer’s career progressed and she became a senior ob/gyn at the University of California, San Francisco, the need for abortion access only became more salient. “Abortion provision and training was just core to what I love and care about as an ob/gyn,” Steinauer told me. As a student, she was one of the founders of Medical Students for Choice, a student-led organization that continues to work to destigmatize abortion training, as well as convince affiliated schools to include “abortion as a part of a comprehensive reproductive health services curriculum.”
“One of our core tenets at the very beginning was that every physician needs to graduate with knowledge about abortion and be able to competently provide compassionate, nondirected pregnancy options, counseling, and referral, no matter what,” Steinauer said. She also emphasized the need for physicians to “work out their own feelings about abortion.”
But anti-abortion groups and Roe detractors were hard at work stacking courts and shoehorning unconstitutional laws so that in 2022, the nearly 50-year effort to overturn Roe and return abortion from a constitutionally protected right to a felony charge reached its peak. The Dobbs v. Jackson Women’s Health Organization decision has allowed abortion to become effectively illegal in half the country. An entire medical field has been thrown into disarray, leaving many practitioners unemployed, morally compromised, and unduly burdened. People with uteruses have to contend with a future without a right that for nearly half a century has been protected in America.
Doctors have historically been cohesive in their ethics and standards, but the Dobbs decision challenges that on the national level. The fight against restrictive abortion bans has to ask whether more providers will join Steinauer in the recognition that these bans will not only have long-lasting effects on women’s care, but will impair all health care, as well as compromise the duty of doctors to their patients and their ethics.
IN 1993, DR. DAVID GUNN, AN ABORTION PROVIDER, was murdered outside of the clinic where he worked in Pensacola, Florida. That same year, thousands of medical students, including Steinauer, began receiving “vulgar and menacing” anti-abortion pamphlets through the mail. Long before the Dobbs decision, reproductive rights had been under assault, in ways that were both crude and insidious. A 1991 study detailing how only 12 percent of ob/gyns received training in routine abortion care illustrated the gap in education.
The Kenneth J. Ryan Program, which Steinauer now leads from her post at the UCSF Bixby Center for Global Reproductive Health, was created in response to the Accreditation Council for Graduate Medical Education (ACGME) mandate requiring abortion training as part of obstetrics and gynecology residencies. The program is partially responsible for the more than 60 percent of providers who now receiving specialized abortion training, when it was able to operate in a world where Roe was considered settled.
Doctors have historically been cohesive in their ethics and standards, but the Dobbs decision challenges that on the national level.
But after the Dobbs decision, at least a dozen Ryan Program iterations that function in states that are restricting or banning abortion face an uncertain future. This means that in states like Louisiana, where abortion is banned in nearly all cases, ob/gyns are forced to either travel out of state or never comprehensively complete their residencies.
In addition, the decision has opened up the risk of a further loss of practitioners in restrictive states. One month after the Dobbs decision, there were 43 fewer clinics offering abortions across 11 states that had severely restricted or banned the practice, according to a Guttmacher Institute analysis. The remaining clinics all operate within states that have six-week bans instead of total bans.
NICOLA MOORE, FAMILY DOCTOR, HAS BEEN an abortion provider for over a decade, and was working with Planned Parenthood of Greater Texas when the Supreme Court issued Dobbs. Moore had been acquainted with severe restrictions in Texas before the decision, due to the Texas Heartbeat Bill (HB 1500) that was passed in late 2021. Under this law, Moore would perform ultrasounds and determine whether there was a heartbeat, making her the last person many would see before they were denied an abortion.
Moore would do her best to inform patients that, while the law prevented her from performing an abortion if she detected a heartbeat, other states, like New Mexico, could be a refuge—but it was hardly a comfort.
“The work was very different after the heartbeat bill because there was a lot more dealing with very emotional things with patients,” Moore told me. She described the demeanor of her patients after the bill as “stressed and frantic.”
Moore also had her own future to worry about. The Dobbs decision would have left her unemployed if not for the fact that she traveled for work regularly, having worked in six other states over her career. Still, the ruling threw her life into disarray. Not only did Moore have to deal with worrying about her next source of income; there was also the emotion of leaving a crew at Planned Parenthood Texas that she had come to dearly cherish.
After Dobbs took away her Texas job, Moore secured her Florida license. She plans to work in Tallahassee, an area she chose out of a desire to be “useful,” and because Tallahassee is closest to the abortion desert in the South. Abortions are banned after 15 weeks in Florida, the least restrictive among the Deep South. In Tallahassee, Moore will be at the intersection of Florida and Georgia, where they have already seen large increases in patients, especially travelers. One NPR affiliate quoted a doctor estimating a 30 to 40 percent increase at a clinic in Tallahassee a month after the Dobbs ruling. As Politico reported, nearly 5,000 women traveled to Florida to get an abortion in 2021.
Moore’s history of traveling put her in a slightly less precarious situation, she told me. Other providers who, perhaps, have families or roots in a restrictive state may not find it so easy to leave.
AARON M. SPRECHER/AP PHOTO
The up-front cost to a patient for an abortion in a state where it remains legal can be burdensome.
Now that Roe has been overturned, the option to travel is more stressful than it may seem. Less restrictive states have seen an increase in patients, as well as wait times, placing a strain on systems and practitioners who have kept their jobs. A month after the decision, the Chicago Sun-Times reported that one clinic in Skokie, Illinois, had seen a 130 percent increase over 2021 of in-person visits. The New York Times reported in July that five out of eight New Mexico abortion clinics had wait times longer than three weeks for an abortion, mostly due to interstate travel.
“The capacity at clinics across the country is stretched,” said Elizabeth Nash, the principal policy associate for state issues with the Guttmacher Institute. In addition, “the train is on the track” for more closures and deeper contraction of providers, she told me.
In some states, the laws are changing so rapidly that providers are unsure of what might happen week to week. Michigan, for example, has been in a legal back-and-forth over an 1846 law last updated in 1931 that makes providing an abortion a felony. The law was struck down in September by the Michigan Court of Claims; in Judge Elizabeth Gleicher’s decision, she asserted that the law “denies women of their ability to control their bodies and their lives.” There will be a referendum on the November ballot to make abortion rights constitutionally protected.
And in states where the law criminalizes performing an abortion, Nash said, “there are very limited exceptions to these abortion bans and there are steep penalties for violating the law. Providers are going to be very risk-averse.”
Abortion bans force doctors to sacrifice legal security or battle internally with the moral question of helping someone over their own livelihood.
Providers worry about their liability when it comes to performing even a procedure they understand to be legal. In states like Oklahoma, doctors can be sued for up to $10,000 for performing an abortion. In most cases, it carries a felony charge. “In Missouri, every abortion must be reported to the state, and prosecutors can request a court order to examine records and confirm a medical emergency was present,” Stat News reported. A prosecutor who wants to make a case against a provider—or simply wreak havoc—has an avenue to do so.
Gretchen Borchelt, litigator with the National Women’s Law Center, constantly fields legal questions from doctors after the Dobbs decision. Doctors wonder if instances that need emergency abortion or miscarriage management are unlawful; Borchelt has even had social workers worried about their liability were they to suggest an abortion.
“There’s not a situation like this where it’s just outlawed, and providers are having to worry about criminal liability for providing care that 1 in 4 women will need in their lifetime,” Borchelt said.
Practitioners also have to worry about who would protect them were they to find themselves needing defense against a restrictive abortion law. This is new territory for lawyers, as well, Borchelt told me. And while insurance covers medical malpractice, a felony charge is rarely insured, and carries with it a loss of licensure in many places. Kate Dielentheis described to me a situation where the thought of being sued by a patient for medical malpractice is the lesser of two evils, between that and being sued by the state for a felony charge. The result of this grotesque cost-benefit analysis can be a patient not getting timely, necessary care.
Dielentheis works in Wisconsin providing obstetrics and gynecology care. An 1849 law banning abortion took effect after the Dobbs decision. As a generalist and ob/gyn, Dielentheis is prohibited from doing “a big chunk” of her job. She expressed frustration about how this old law can disrupt such an important part of her and other women’s lives.
“This is a law that came before ultrasounds, before the modern-day pregnancy test. This was a law that came so far before the vast majority of our medical knowledge,” she said. “It’s really hard to take that law and extrapolate it to how we practice medicine because a lot of this wouldn’t have been recognized in 1849.”
Dielentheis also trains residents, but she is no longer able to provide abortion training in the state of Wisconsin. She and other doctors are working on a way to create connections with other programs so that they can provide the full scope of training to the many residents who feel this training is essential.
“From a health care perspective, it’s incredibly important that they have that training in order to be able to take care of patients in the future,” Dielentheis said.
Doctors swear the Hippocratic oath, declaring that they will do no harm and work only to aid people medically. Abortion bans are in direct conflict with this oath, leaving doctors in a position where they must sacrifice legal security or battle internally with the moral question of helping someone over their own livelihood.
The resulting emotional deliberation forces doctors into an uncomfortable position. Ultimately, many feel sad and angry to be put in this position. Sarah Prager, an ob/gyn at the University of Washington in Seattle, has seen a lot of gratitude from her patients. But it brings her no joy.
“I don’t feel like you should be grateful to have what is routine health care that, in the last 50 years, has been accessed by a third to a quarter of all people with a uterus,” she said.
STEINAUER’S FAMILY DID NOT JUST DECIDE one day that abortion was important. This family, like millions, went through the stigma around unintended pregnancies and abortions before Roe was handed down.
After Steinauer graduated from college, she learned that her mother had been pregnant before her with her half-sibling who was put up for adoption and eventually reconnected with the family. Then, she learned of two other women in her family having unintended pregnancies, as well. One had a pre-Roe abortion and the other was wed as a result.
“I had all three outcomes of an unintended pregnancy, right in my family unit,” she said. “That definitely made it clear.”
JEFF CHIU/AP PHOTO
Jody Steinauer was a founder of Medical Students for Choice, and today works as a senior ob/gyn at the University of California, San Francisco.
It is “extra sad” for Steinauer to think about how prior family generations might feel about the Dobbs v. Jackson ruling. The emotion that comes with having a right stripped away, after being unilaterally protected, is a tough one. Steinauer knows this professionally and personally.
When it becomes clear that their hands are legally tied, doctors are seeing patients upset, angry, and frightened. Many patients have to spring into action arranging transportation, funds, and support as they prepare to travel out of state.
If a patient is able to secure an appointment and timely transportation, the up-front cost of an abortion is additionally burdensome. Abortions can cost up to $2,000 out of pocket. According to a study published in the journal Women’s Health Issues, among patients who traveled 50 miles or more, nearly 60 percent reported difficulties related to missing work; more than 35 percent reported delays due to financial costs. This is further complicated by many states barring the use of Medicaid for nonresident patients. Then there are the costs associated with travel. Patients may have to worry about gas money, plane tickets (or car rentals), child care, and lodging.
In addition to the logistical frustration and general emotion doctors are seeing, Dielentheis noted the incredulousness she faces from patients. When she tells them that—even in the event of a nonviable pregnancy—she cannot help them, “people are surprised, and they’re frustrated, and they’re angry,” she said.
Hospitals have been facing staffing and funding shortages for years. With the Dobbs decision, Bloomberg reported that “[s]pecialists in obstetrics and gynecology—frequent targets of medical malpractice lawsuits—especially are wary of taking jobs in states where the laws could limit their practice.” There has also been a particularly devastating contraction of rural hospitals.
Now, providers are considering whether they can stay in their state and provide care that fits their conscience, or even adequate care. And the residents that end up receiving training in another state may elect to not come back. As Roll Call reported, “The choice of where to train could have a long-term effect,” as over 55 percent of doctors practiced within the same state they received the training.
“Many of [the residents] are electing not to stay in Wisconsin,” Dielentheis said. “It’s going to be harder to get people to work in certain areas, where care is really needed.”
And an important pipeline has now been removed. Catholic hospitals have never performed elective abortions. Before the Dobbs decision, however, some Catholic medical professionals were able to essentially outsource patients who needed an abortion to a clinic or hospital that would or could perform the surgery. Without Roe v. Wade to protect those institutions and the care they provide, access is further restricted and the Catholic absolute ban becomes law in dozens of states.
“We now have no backup plan for those patients in the states with abortion bans,” said Lori Freedman, a researcher on Catholic hospitals with the Bixby Center. “Catholic health care has been dependent on the providers to pick up where they are and to prevent harm.”
For Prager, maternal mortality rates rising as a result of the Dobbs ruling is about “when,” not “if.” The United States already has a disproportionately high maternal mortality rate among developed countries.
In states where abortion is permitted in the event of a medical emergency or “to save the life of a mother,” the vague distinction has left hospitals and patients reeling. Doctors are being forced to wait until a person is on the verge of death, hesitating out of fear that acting too early could be interpreted as an illegal abortion. Providers need to run a decision to help a patient up the hierarchical ladder of the institution, and administrators then consult with legal and ethics boards before passing down a decision on whether a doctor can save a life.
Providers also report that more people are coming in inquiring about permanent sterilization. Prager is used to performing maybe ten sterilization procedures a year in just her clinic; she says the number has jumped to eight to ten approvals for the procedure per month.
“These are people who are in their twenties, who have never had children and don’t ever want to chance it,” Prager said. “They now don’t feel secure in the fact that they will have options.”
“People are not realizing how this has really impacted desired pregnancies as well,” Dielentheis said.
The lack of control that people have over this personal decision is alarming. It is a gross manipulation of the medical system, placing countless barriers in the way of someone obtaining care they need. State legislatures were not prepared for the way this decision would impact the entire health care system. Drugs with dual purposes—abortifacient and non-abortifacient—such as methotrexate, are being restricted. Contraception and other forms of reproductive care are being threatened; all the while, patients with uteruses suffer.
WHILE THE FUTURE LOOKS BLEAK AND HOSTILE, reproductive rights groups are hardly backing down. Abortion could still be codified into law, through either federal or state legislation or referenda or, as Borchelt sees it, even a constitutional amendment.
And there have been surprising successes, such as Kansas’s landslide vote against a restrictive anti-abortion law. Meanwhile, doctors and patients alike are rising up to protest for their autonomy. There have been numerous national protests in the aftermath, from Washington, D.C., to New York, Chicago, and San Francisco.
The popular backlash against the Dobbs decision, and the impractical, cruel ways that several states are carrying it out, has energized progressives and surprised the anti-abortion lobby. What remains to be seen is whether more doctors will join this struggle, in the spirit of medical leaders like Jody Steinauer.
The medical profession is notoriously risk-averse and heavily commercialized. With the exception of the activist doctors who battle for abortion rights and single-payer health insurance, physicians tend to shun controversy. But now controversy that doctors didn’t seek has come to them—and their professional autonomy and duty to their patients are at risk. Whether reproductive rights and women’s health as a right will be defended could very well depend on whether the medical profession as a whole leaves its comfort zone.
