Abortion-Restrictive States Leave Ob-Gyns With Tough Choices

IRA FLATOW: This is Science Friday. I’m Ira Flatow. Roe versus Wade was overturned almost two years ago now. And a lot has changed when it comes to abortion choices in the US.

Some states have effectively banned abortion. Others have such confusing laws that it’s difficult for the people who live there to know what their reproductive rights are. How has the post-Dobbs landscape affected the people who work in this field? Joining me today are two physicians in two states that have limited abortion access, Dr. Sara Thomson, an OBGYN based in Boise, Idaho, and Dr. Abby Cutler, an OBGYN and assistant professor at the University of Wisconsin School of Medicine and Public Health based in Madison, Wisconsin. Welcome, both of you, to Science Friday.

SARA THOMSON: Thank you for having me.

ABBY CUTLER: Thanks so much for having me.

IRA FLATOW: Thank you for being here. Dr. Cutler, I want to start by getting a quick understanding of how abortion access has changed in your state. What’s the landscape like in Wisconsin?

ABBY CUTLER: The short answer to your question is that the legal landscape in Wisconsin right now looks, by and large, pretty similar to the pre-Dobbs landscape in Wisconsin, but that’s a recent change. So it bears explaining what’s happened to abortion access in Wisconsin since Dobbs was decided two years ago. Pre-Dobbs law in Wisconsin imposes a number of limitations on the provision of abortion services here in our state. So to name a few, we have a mandated 24-hour waiting period, a 22-week ban with limited exceptions, a ban on telemedicine in the use of abortion provision, and many other laws and various barriers, like a general lack of insurance coverage, for example, for abortion that makes it really challenging to both access and provide abortion care for patients and providers alike.

Abortion care provision basically stopped the day Roe fell except in circumstances where providers felt they could legally intervene to save the life of the mother, which was difficult to determine. Our attorney general quickly filed a lawsuit in the fall of 2022 seeking clarity on whether that law was valid. But in the meantime, Wisconsinites who needed abortion care were forced to leave the state to access that care. But in the meantime, as of a couple months ago, many of us providers in Wisconsin can and have resumed providing abortion services following the same set of legal restrictions that applied pre-Dobbs, if that makes sense.

IRA FLATOW: Yeah. Well, that’s what I was going to– is there confusion here among providers and patients?

ABBY CUTLER: Yes. I think it’s impossible to undo the 18 months of time where abortion was interpreted to have been banned in our state. And so it really varies across the state whether health systems and providers have resumed abortion services, if they ever provided them in the first place, because that also varied prior to Dobbs. And I think there’s still quite a lot of confusion among patients as to what they can legally access here and whether they need to leave the state to access the care that they need. So yeah, it’s been a mess.

IRA FLATOW: Yeah. And Dr. Thomson, in Idaho, what are the circumstances there about abortion legality?

SARA THOMSON: The circumstances are extremely limited. The way our law is written is that anyone who performs an abortion of a clinically-diagnosable pregnancy is guilty of a felony unless it is to prevent the death of a pregnant woman or in cases of reported rape or incest, but only with a police report and only in the first trimester.

IRA FLATOW: Wow.

SARA THOMSON: The penalty is two to five years’ imprisonment and suspense of a medical license for anyone who assists. We also have another law that includes a civil penalty that allows a pregnant patient or family members to sue medical professionals for performing an abortion for a minimum of $20,000.

IRA FLATOW: Wow. Last month, a report from the Idaho Coalition for Safe Healthcare said that 22% of OBGYNs have left Idaho since Roe versus Wade was overturned. Wow. Have you seen that migration, Sara, in your own eyes?

SARA THOMSON: Yes, I have. And I can tell you that no physician is making that decision to leave lightly. Many of us have had a crisis of conscience about what to do, feeling both deeply committed to our patients, but also concerned about what this means for us personally and for our own families.

No OBGYN in our state is spared the stress of this law because every OBGYN has been in a situation where we’ve had to induce labor for a mother’s health being in jeopardy at a gestational age where the baby will not survive. And the threat of incarceration for five years for patient care is just too much of a burden for a lot of physicians. And being told that no physician has been prosecuted yet or that a case of medical necessity is unlikely to be prosecuted is not adequately reassuring.

Physicians don’t want to be in a situation where we’re having to test the boundaries of the law or perform acts of civil disobedience that places at risk of being incarcerated. Like most people, physicians want to be sure we’re legally secure in our work. And that’s hard to do right now because our laws were not written in a way that compassionately considers some of the pregnancy complications that we encounter.

IRA FLATOW: Wow. And Abby, what about in Wisconsin? Are OBGYNs leaving that state too?

ABBY CUTLER: I’m not aware of any data documenting an exodus of OBGYNs out of Wisconsin. I can tell you that I know several OBGYNs who, after Roe fell, left Wisconsin and crossed state lines in order to continue to provide abortion care, oftentimes for our own patients here in Wisconsin, who as I mentioned were also having to leave the state to access that care. I can also talk a bit about research we’re conducting here at the University of Wisconsin, which does illustrate that some OBGYNs certainly have contemplated leaving the state because of how the post-Dobbs legal landscape threatens their ability to practice medicine, and not just their ability to provide abortions, but their ability to provide standard evidence-based pregnancy care to their patients, especially when a pregnancy-related complication arises, in the ways Dr. Thomson was just illustrating.

And almost all the OBGYNs we’ve interviewed have expressed concern that the post-Dobbs legal landscape here has jeopardized our ability to train, recruit, and retain OBGYNs. It’s also worth noting, though, that many OBGYNs we’ve interviewed have expressed a commitment to staying in Wisconsin for a multitude of reasons, including a commitment to continue to care for their own communities. But I do think this commitment to Wisconsin is contingent on some things, an optimism that abortion access would eventually return to Wisconsin, at least temporarily, like we’ve seen in recent months, having or trusting in some minimal amount of support from their institution or their health system to have their backs, and also just general security and stability in other areas of their work.

IRA FLATOW: Right. Sara, is there any optimism, like Abby has in Wisconsin, about possibly abortions returning, the law changing at all in Idaho?

SARA THOMSON: Well, no. I mean, I don’t think there’s a lot of optimism amongst my physician community. And I spoke with someone last week who told me he was feeling kind of hopeless about this situation.

Our state legislature is only in session from January through March. And at the beginning of the session, we were hoping we would get at least a maternal health exception, but that has not happened so far. And I’m very disheartened that there’s been no bill introduced by our legislature to protect pregnant women with a health exception. Being able to care for pregnant women safely without a threat of criminal prosecution could really help stem the loss of our OBGYN workforce.

And I understand that our Idaho legislators may not have anticipated that this would happen because when the laws were written, it was prior to Dobbs and this legislation felt probably more theoretical. But now that we’re seeing the consequences of criminalizing health care with only a prevention of death exception, I really would expect more in terms of changes. One of my obstetrician colleagues told me she’s willing to give our legislature some time to fix this, but she won’t stay in the state indefinitely if our laws aren’t changed. And she’s certainly not alone in that sentiment.

IRA FLATOW: That is amazing. I know that both Wisconsin and Idaho have large rural areas. Sara, how has OBGYN care in these regions changed?

SARA THOMSON: Well, that’s really the tragic consequence of Idaho’s criminal abortion ban. Now we have fewer OBGYNs left in the state to provide prenatal care and to deliver babies. And we’ve had three hospitals close their labor and delivery units in our state. And over half of our high-risk maternal fetal medicine specialists have left full-time practice in the state. And we only had nine MFMS in our state to begin with before the law changed.

A pregnant woman in Idaho will likely have to wait longer for an appointment and have limited access to specialists. And especially in rural areas, she may find herself in an expanding maternity desert with no obstetrician in her town or city and may have to drive more than an hour for prenatal care or to deliver her baby. And this is going to have a disproportionate impact on women in our community who already have barriers to care, especially if she lacks transportation or has limited financial resources or has limited child care options for her other kids. And really, even if a pregnant woman has optimal resources, if she experiences a rapid labor, she might find herself having an unintended, out-of-hospital birth because the closest labor and delivery is now further away.

IRA FLATOW: Interesting. Abby, I know you’ve been collecting data about how the post-Dobbs landscape is affecting the future of OBGYNs, specifically young people in med schools who now have to decide if they want to work in reproductive health as their specialty. What have you learned? Has this stifled that interest?

ABBY CUTLER: It’s definitely raised concerns. I’m involved in a very interesting study that’s not yet published, but analyzes posts from the social media site Reddit in which pre-medical and medical students were posting about discussing the impact of the Dobbs decision on their professional decision-making. We looked at posts on Reddit between May 2, 2022, which was the date of the Dobbs Supreme Court case leak, to August 24, 2022, just two months after the Dobbs decision came down.

And over that time in these posts, medical students, and residents as well, were expressing significant concern about the Dobbs decision’s impact on their professional futures, particularly in relation to abortion training and education. Pre-medical students and medical students spoke about how the decision, the fall of Roe, had influenced their choices regarding specialty selection, meaning what specialty of medicine they were planning to apply into. And this was particularly concerning among those who had been most interested in going into obstetrics and gynecology. And it was shaping decisions among those folks on where to apply for medical school and for residency training. Students and residents expressed apprehension about also the potential decline in the quality of medical education and training they might receive in states with restrictive abortion laws.

I’m also involved in a study we’re conducting here in Wisconsin that explores the experience of OBGYN residents who are forced to leave the state to access abortion training because of the impact that Dobbs had here in Wisconsin. And themes that have come out of those interviews include moral distress over both the need for having to leave their home state in order to get this training, distress over an inability to fully care for patients when they returned to their home state, and also shifting plans when it comes to post-training career goals and intentions.

IRA FLATOW: A big post-Dobbs decision that made a lot of headlines recently was Alabama’s IVF ruling, where the state Supreme Court said that frozen embryos should be considered children. And there have been some changes to this to protect providers from criminal liability, but what was it like to see this ruling in another state? From what I’ve seen on the media coverage of this, a lot of legislators had no idea that this would stifle women having children where they’re trying to encourage women having children.

ABBY CUTLER: I do think that case really demonstrates how far the Dobbs decision and the fall of Roe, meaning the removal of the constitutional right to bodily autonomy when it comes to pregnancy, extends to all sorts of pregnancy-related situations that are not necessarily directly about abortion. And so I do think that legislators weren’t necessarily prepared for the ripple effects that Dobbs would have, even though OBGYNs in our profession have been trying, many of us, to sound the alarm for a long, long time about what would happen if that right were to be taken away.

IRA FLATOW: This is Science Friday from WNYC Studios. Talking about the loss of OBGYN services and people since the overturn of Roe versus Wade. And Sara, in the post-Dobbs landscape, is it affecting Idaho’s recruitment of OBGYNs from out of state?

SARA THOMSON: Yeah, absolutely. As doctors move out of our state or retire, we’re having a real difficulty replacing them. Idaho has no OBGYN residency training program, so we can’t recruit new OBGYNs from within our borders. And out-of-state applications to our open positions have decreased dramatically for both private practice and hospital-employed practices.

In this 15-month period that this report recently examined, we had 58 out of 268 physicians practicing obstetrics stop in our state, and only 2 obstetricians moved to Idaho in that same time period. So that’s a really uneven balance there of number of people who are no longer practicing OB versus the number of people who are willing to move here to take their place. And I’ve also spoken to traveling physicians, they’re called locum tenens, who are reluctant to come to Idaho for assignments because they’re worried their insurance only covers medical malpractice and not criminal liability.

IRA FLATOW: Wow. I hadn’t heard of that before. That is amazing.

SARA THOMSON: The other thing, Ira, that I think is important to highlight here is that this recruiting problem is not only limited to OBGYN. Our local paper here in Idaho reported last week that an emergency medicine physician declined an offer because he was not willing to come to a state that criminalizes physicians. And I’ve heard of another doctor in a different specialty declining an offer because his wife wasn’t willing to move to Idaho.

And OBGYNs are also commonly married to other physicians, so we’re losing physician spouses, as well. And we know that from 2021 data that Idaho already has the lowest number of doctors per capita of all 50 states. So this is a serious problem for our entire population and not just for those people in our population that are pregnant.

IRA FLATOW: Well, given all those statistics that you’ve just quoted me, despite all the difficulties you’ve outlined today, you are still practicing in Idaho. What keeps you there?

SARA THOMSON: Well, yes. I’ve decided to stay because this is my home. But I will tell you that in the last year, I updated my resume for job-seeking purposes for the first time in 10 years.

IRA FLATOW: Wow.

SARA THOMSON: But in staying here, I feel obligated not just to continue caring for pregnant women in my community, but also to speak up on behalf of my patients who have been harmed by the law, as I don’t think they should be the ones who are having to shoulder the burden of redress for this situation. Physicians really need to find our voices right now to let our legislature know that this is a problem. In Idaho, we don’t have a single physician in our legislature. So it’s really important now to have conversations and try to communicate with our lawmakers to let them know that patients are being harmed.

IRA FLATOW: Wow. I don’t think any of us have realized the overarching effect of this decision. And I want to thank you both for sharing what you know and enlightening us about what life is really like. Thank you both for taking time to be with us today.

SARA THOMSON: Yeah. Thank you for having us.

ABBY CUTLER: Thanks for having us.

IRA FLATOW: Dr. Sara Thomson, a practicing obstetrician based in Boise, Idaho, Dr. Abby Cutler, an OBGYN and assistant professor at the University of Wisconsin School of Medicine in Madison.

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