The State Of Reproductive Health, One Year After Dobbs

JOHN DANKOSKY: This is Science Friday. I’m John Dankosky.

DIANA PLASKER: And I’m Diana Plasker. It’s been a little over a year since the Supreme Court overturned the federal right to an abortion. Since then, we’ve seen states jump into action. 13 have banned abortion with limited exceptions. Three more have banned abortion after the first trimester. And a handful of other states have extremely restrictive access to abortion or otherwise remain in legal limbo.

Last year, we dug into the science of reproductive health care in the US. Today, we’ll follow up to get a better sense of this new reality. I’m joined by Usha Ranji, Associate Director for Women’s Health Policy at the Kaiser Family Foundation based in San Francisco, California. She recently co-authored a report which surveyed just under 600 ob-gyns from across the US about their experiences. Usha, welcome to Science Friday.

USHA RANJI: Thanks for having me.

DIANA PLASKER: Well, let’s start off by talking about states where abortion has been banned. What are ob-gyns reporting on how their patients are able to access abortions across state lines?

USHA RANJI: We have now many states that have banned abortion, except for very, very limited exceptions. They’re heavily concentrated in the southern part of the United States. And what we heard was that, overall, half of ob-gyns who practice in those states say that they have had patients in their practice who were unable to obtain an abortion that they were seeking in the past year.

DIANA PLASKER: And the states with abortion bans or severe restrictions are concentrated in the South and Great Plains. What’s been the effect of this big block of states with abortion bans?

USHA RANJI: Yeah, that means for patients, for people living in those states if they are seeking abortion services, for the most part, they need to travel out of state. And depending on exactly where someone lives, that can be really far. It may mean several miles. It also depends what stage of pregnancy they’re in before they can obtain abortion services.

So what we’ve seen from other research, is that there has been an increase in states where abortion remains legal. There has been an increase in patients coming from out of state. What this survey also shows is that a lot of people just are not getting the abortion care that they’re seeking. And so that means that they are having to continue the pregnancy.

DIANA PLASKER: So even before this decision in the US, there are huge disparities in who has access to timely and affordable reproductive health care. Has this decision further deepened that divide?

USHA RANJI: Well, I think that’s a good point. Many of the states that have now banned abortion since the Dobbs ruling, already had great limits on abortion access. The state of Mississippi, for example, only had that one clinic providing abortion services prior to the Dobbs decision. So access was already limited.

In those states where abortion is now banned, there are virtually no ob-gyns providing abortion services. Some do provide referrals out of state. But we also see that 30% of ob-gyns in states with abortion bans are not offering their patients referrals or even any information about abortion services. So it does absolutely make a bigger difference.

DIANA PLASKER: And it doesn’t just seem like it’s only affecting abortions. This can also impact miscarriage care and other pregnancy-related emergencies. What did your research find in that case?

USHA RANJI: Yeah, absolutely, I think what some people don’t realize is that the same medicines and procedures that are used for abortion are often used to manage miscarriages, as well. And miscarriages are really common. So what we saw was that nationally, 1 in 5 ob-gyns said that they personally have felt constrained in their ability to provide care for patients who are experiencing miscarriages or other pregnancy-related medical emergencies since the Dobbs decisions.

But again, it is much higher in states with abortion bans. It’s 40% of ob-gyns that they personally have been constrained in caring for patients who are experiencing miscarriages.

DIANA PLASKER: Wow, so it just seems like the effects are just so widespread. You also found that the type of birth control that patients were seeking has changed too. Tell me a little bit about that.

USHA RANJI: More than half of ob-gyns nationally across the US say that they have had seen an increase in the share of patients seeking some form of contraception in the past year and particularly, sterilization and the longer acting methods, IUDs and implants.

So 43% of ob-gyns said that they’ve had an increase in patients seeking sterilization services, that is getting tubes tied. And about the same share saying that they’ve had an increase in patients asking for IUDs and implants.

DIANA PLASKER: Well, what’s happening in states where abortion remains legal? What are the differences?

USHA RANJI: In states where abortion remains legal, doctors are still affected in the provision of care. Some of the states where abortion remains legal now, it’s not clear that it’s going to remain legal going forward. There are several cases pending in Iowa.

You may have heard the governor there held a special legislative session, specifically, for restricting abortion access. The state legislature actually passed a law that restricted that restricts abortion access, but then just a day or two later, is not in effect due to a court order. But that’s a lot of change in policy in a very short amount of time. And so that can create a lot of confusion for doctors and patients in those states.

DIANA PLASKER: What does this mean for the future of abortion care and reproductive health at large?

USHA RANJI: Yeah, I think looking to the future, we asked ob-gyns about what they think the effects are down the road. And over half said that they think that the ability to attract new ob-gyns to the profession, has actually gotten worse because of Dobbs. And those are concerns that are shared by ob-gyns in states with different abortion policies.

I think that’s something we really want to watch because some of the states that have banned abortion, already had severe clinician shortages and also had some of the worst maternal health outcomes. And now ob-gyns are telling us that there’s the possibility that those are going to be exacerbated in the post-Roe world.

DIANA PLASKER: Thank you so much. We’ve gotten to the end of our time together, Usha. And I just want to thank you so much for this report and for taking time to be with us today.

USHA RANJI: Thank you.

DIANA PLASKER: Usha Ranji is Associate Director for Women’s Health Policy at the Kaiser Family Foundation based in San Francisco, California.

JOHN DANKOSKY: As we just heard, there’s a big disparity between states where abortion is banned or severely restricted versus those states where it remains legal. So we wanted to speak with a doctor who’s navigating some of these realities practicing in a state where abortion is legal and protected but seeing patients who are traveling from states with bans in place.

Dr. Rebecca Cohen is the Medical Director of the Comprehensive Women’s Health Center based in Denver, Colorado. Dr. Cohen, welcome to Science Friday.

REBECCA COHEN: Thank you so much for having me.

JOHN DANKOSKY: So to start off, give us an overview. What’s different about the patients that you’re seeing since last year’s Dobbs ruling?

REBECCA COHEN: Yeah, there have been really a lot of changes. First, as you mentioned, we are seeing a lot more people from out of state. Before the Dobbs decision, only about 1 in 20 of our patients came from outside of Colorado. And now it’s closer to 1 in 3 primarily from states that are nearby Colorado, like Texas, but truly, from across the country, as it becomes harder and harder for people to seek care.

We are also seeing more people for abortion care later in pregnancy. Often, because it’s taking such a long time to navigate the logistics and the barriers of finding child care of getting a flight, and a hotel, and an appointment. But also just because there are so many fewer places now that can care for people who have developed complications of their pregnancy beyond the first trimester.

JOHN DANKOSKY: So what’s the impact on patient’s care when they do have to travel so far to get to your clinic.

REBECCA COHEN: Yeah, there are a lot of impacts, unfortunately. Really, what we’re seeing is a lot of stress from being in and navigating an unfamiliar environment. So instead of being able to go to a doctor that they know in a city that they live, they have to take more time off of work. They have to go to an airport, potentially, that they’re unfamiliar with, get a car, and trust strangers in a time that is really stressful.

All of that also involves a lot more expense. So abortion care is often not covered by insurance. So people are paying out of pocket. But then they have the additional expenses for travel and lodging and again, time away from work or school.

JOHN DANKOSKY: So on the program, in the past, we’ve talked about what the expansion of medication abortion versus surgical abortion could mean, in a post-Roe landscape. So what is the ratio of surgical versus medication abortions that you’re seeing?

REBECCA COHEN: Yeah, so that’s actually more of a complicated question than it seems at first. Because my practice, ironically, is seeing fewer patients now for medication abortion precisely because the options have expanded so drastically since the Dobbs decision last year.

It used to be that for a medication abortion, we had to see someone face to face, even just to provide the medication. And during COVID, those rules were lifted. And Colorado has been at the forefront of expanding medication abortion access through telemedicine, so remote visits through use of what we call advanced practice providers like nurse practitioners and nurse midwives.

So even though my practice is seeing fewer people seeking medication abortion, we know that there are more now than 10 organizations offering medication abortion in Colorado. And so a lot more people are having access to it.

JOHN DANKOSKY: Are you also seeing more patients who are seeking care for miscarriages or pregnancy-related health issues who are traveling from out of state because they can’t get care in their home states, or they’re not sure if they can get care in their home states?

REBECCA COHEN: Yeah, absolutely, and that’s been one of the hardest parts of this for everyone involved. So for patients, for providers it’s just the uncertainty of what is allowed and what is not. Generally speaking, we have pretty well-defined guidelines for how to say this is a miscarriage or this is an ectopic or tubal pregnancy. Those are not considered viable pregnancies. They will not proceed to a live birth, and so we’re generally able to intervene quickly for medical safety.

But as people have been so concerned to say, well, this could be perceived as providing abortion care, so doing a procedure to end a miscarriage, intervening in an ectopic pregnancy they’ve made the guidelines or kind of brought on these guidelines that are much more stricter than what is medically necessary.

We’re also seeing patients that are just– they are too scared to seek care within the formal health system. I have cared for patients in the past who would take a positive pregnancy test at home, and then rather than go to a doctor to say, hey, I got this test, can you confirm that I’m pregnant? If they know they don’t want to be pregnant, they become afraid and just go.

So we have seen people now, a few times over the last year, that when we see them in our clinic after that, again, 10, 12, 14-hour drive, we found out that they’re not pregnant. That they may have miscarried recently in the past, or they may have misread the test. And so people are really going these extraordinary lengths for care that could be provided in their home state but because of fear, is not.

JOHN DANKOSKY: And that’s a really important distinction. People who in the past, might have right away gone to a doctor and said, well, let’s find out if I’m pregnant right now. Knowing that you’re pregnant, if you’re not sure you want to carry the pregnancy to term, that can be a problem in a lot of states.

REBECCA COHEN: Absolutely, because there are times where it’s imperative that someone seeks care. And one of those times is if there is a possibility of an ectopic pregnancy. So a pregnancy growing outside of the uterus in a space that it can’t be sustained, that pregnancy can rupture. So it can outgrow the Fallopian tube, tear open, and cause very dangerous internal bleeding.

And there have been times where people are so afraid that if it’s not an ectopic pregnancy, or if it’s deemed not dangerous enough yet, that they may get in legal trouble in their home state. So they take that risk to their own health of going outside of the place that they are to seek care, even when it’s medically advised to seek care closer because of the legal risks.

JOHN DANKOSKY: If you’re just joining us, we’re talking about the state of reproductive health one year after the overturn of Roe v Wade. I’m John Dankosky. This is Science Friday from WNYC Studios.

One of the things that we heard earlier is that a lot of ob-gyns in the US are worried about increasing disparities in access to reproductive health care and abortion. Have you seen some of these disparities at play where you work?

REBECCA COHEN: We have, and it’s really at every level. What we know is that when abortion care is restricted or banned, it takes more resources to find it. That is everything from health literacy or understanding how to navigate the health care system. It’s having a computer or a smartphone to be able to look up information about where to go to get an abortion.

It’s understanding what is and is not legal in the place that you live to find that information to make those arrangements. And then, again, it really is about having the financial and logistical support to overcome what is becoming bigger and bigger barriers in terms of making travel arrangements, being able to spend the money and have time away from family, work, school without having such a negative or insurmountable impact on your life.

JOHN DANKOSKY: We’ve also been reading that medical training is starting to change in states where abortion is illegal. And medical residents are trying to find training opportunities elsewhere. So have you seen an uptick in medical residents or nurses who want to train at your clinic?

REBECCA COHEN: Yeah, we’ve gotten a lot of interest. And the challenge with procedural specialties like abortion, is that it really does require experience to get the skills to be safe. And so although we’re seeing an increase in volume, it’s not to the point that my particular clinic can safely double the amount of people that we’re training. Definitely, getting people trained to a point that they are safe when the training opportunities have been so drastically restricted, is a big problem for our field going forward.

JOHN DANKOSKY: That’s what I was going to ask. Going forward, do you see that it’s possible that we will just not have enough ob-gyns and nurses trained in this work that we just won’t have enough people to provide the care?

REBECCA COHEN: Yeah, and you mentioned equity earlier. And this is definitely a huge equity issue for people in restricted states. We know that ob-gyns are choosing not to practice in areas where their practices are so curtailed or where things that we can do safely and should be doing safely are not allowed.

And the other is that abortion care is not important only for providing abortions, but it’s incredibly important for an ob-gyn to understand how to manage a miscarriage, how to manage a complication of a pregnancy, and how to do things like provide contraception, which are often also restricted in those same ways.

We also know that restricting abortion leads to increases in maternal mortality, in infant mortality, as people who are not healthy enough to carry a pregnancy to term safely, are often forced to by those circumstances or to give birth to a child who’s also not healthy.

JOHN DANKOSKY: There are a lot of medical realities of pregnant people that you’ve talked about. And many of those are overlooked in conversations about access to reproductive health care. Before we leave, I guess I’m wondering if there’s anything else you wish people would know when they think about access to abortion or reproductive health care?

REBECCA COHEN: It is not just about access to abortion. These restrictions take place in the setting of inequitable care. The states that are most restricting access to abortion are also the ones that generally provide the least support for contraceptive care, for prenatal care, for postnatal care. And all of those things have impacts on women, on children, on families. And that merely limiting or restricting access to abortion is not the way to make people healthier or safer.

JOHN DANKOSKY: That’s all the time we have. I want to thank our guest Dr. Rebecca Cohen is the Medical Director of the Comprehensive Women’s Health Center based in Denver, Colorado. Doctor, thanks so much for joining us.

REBECCA COHEN: Thank you so much for your time.

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