The Supreme Court's June 24 decision to overturn Roe v. Wade has had a domino effect on all aspects of reproductive health as clinicians work to navigate what it means for their practices and patients alike.
More than 40 abortion clinics have closed as of July 29 since the Dobbs v. Jackson Women's Health Organization ruling, with another 200 set to close if intended bans are implemented. But the impact of the decision spans far beyond just clinics.
Physicians have reported a spike in tubal sterilization requests. Some systems have delayed life-saving pregnancy care out of fear of violating state restrictions. The American Board of Obstetrics and Gynecology is set to hold a virtual certification exam this fall due to test-takers' safety concerns. Fertility patients are beginning to move their frozen embryos to states protecting abortion.
To understand how the Dobbs ruling has affected OB-GYNs' practices, patient relationships and career satisfaction, Becker's recently spoke with Katie McHugh, MD, an OB-GYN and abortion provider in Indiana, and Greg Marchand, MD, an OB-GYN in Arizona.
Complicating pregnancy care
After the Dobbs ruling, Dr. McHugh, who also serves as a liaison for the American Medical Women's Association, pivoted her practice to exclusively provide abortion care in Indiana until a "near total" ban takes effect Sept. 15, according to IndyStar. The move makes Indiana the first state to pass new legislation restricting abortion access since Roe's overturning.
With existing abortion bans in Ohio and Kentucky, providing as much access to abortion care as possible in the final weeks it's legal in Indiana has become a "moral imperative" for Dr. McHugh.
"We have worked with multiple clinics and increased abortion access in Indiana by two to three times depending on the clinic, doubling and tripling numbers of appointments," she told Becker's.
"It has been incredible to see the volume increase as well as the distances that people are having to travel just to seek regular, normal abortion care," she said, adding that patients are coming from as far as Tennessee, Alabama, Georgia and Texas.
Physicians in states where new abortion restrictions have already taken effect are grappling with "profound confusion" regarding what kind of care can be provided to patients, according to Dr. McHugh. This confusion and fear of litigation has spurred delays and denials for incomplete miscarriages, ectopic pregnancies and other common complications. Some of the confusion surrounds state laws that allow life-saving care when a woman's life is in danger. In many cases, physicians are consulting attorneys and hospital ethics committees regarding these decisions.
"I've seen a number of patients be transferred to my state from neighboring states, simply because the physicians in the neighboring states are unsure about how much they're allowed to do without committing a crime, being fined or going to jail," Dr. McHugh said.
Dr. Marchand, an accredited master surgeon at Meza, Ariz.-based Marchand Institute for Minimally Invasive Surgery, said he hasn't observed many changes in his own practice thus far, other than referring more patients to California after 11 weeks for abortion care.
"Right now all abortions are paused except for a few private providers, but everyone expects them to be legal before 15 weeks as the new law (SB 1164) states," he said. "No one expects that we're going to bring back the old law that predates statehood and make all abortions illegal."
Magnifying physician burnout and moral injury
The Dobbs decision profoundly affects not just OB-GYNs, but all healthcare professionals, as it implies that physicians cannot be trusted to make medical decisions with patients, thereby setting a dangerous precedent that a politician or law must be included in these discussions, according to Dr. McHugh.
"This does nothing except exacerbate healthcare worker burnout, because it continues to undermine us as autonomous people. It undermines our education and experience," she said.
Under heightened abortion restrictions, OB-GYNs will increasingly be tasked with caring for patients who they know how to treat but cannot due to legal restrictions. The resulting harm to patients will weigh heavily on physicians and cause moral injury, spurring some OB-GYNs to leave the field entirely, according to Dr. McHugh.
"I do think that this is going to contribute to the physician suicide epidemic because we feel so injured and traumatized by the harm that we are forced to cause to our patients," she said. "That is not a sustainable way to practice medicine. It is not a sustainable way for a physician to have a career that they enjoy."
With nearly half of all U.S. OB-GYN residents in states where abortion is banned or likely to be banned, experts expect an "influx" of students to seek opportunities elsewhere, NPR reported Aug. 10.
"Our residents are devastated," Nicole Scott, MD, the residency program director at Indiana's largest teaching hospital, told NPR. "They signed up to provide comprehensive health care to women. And they are being told that they can't do that."
Altering patient relationships
The ruling and subsequent abortion restrictions have also affected some OB-GYNs' relationships with patients. Dr. Marchand said misinformation surrounding the legal landscape — some of which comes from "extreme" sources — has led to more questions from patients.
"[Some] believe that it's illegal to help patients when their lives are in danger, for ectopic pregnancies, treating miscarriages, treating pregnancies where the water has broken [and] infertility treatments," he said, adding that he's "happy to help them understand."
For Dr. McHugh, what used to be lighthearted conversations with patients have changed into "very politically motivated discussions." Instead of typical chitchat about a patient's life or children, many conversations revolve around the patient's desperation to secure an abortion before Indiana implements its ban.
"They also talk a lot about how they fear for their friends and sisters and daughters. And the lack of access that those people will encounter," Dr. McHugh said, noting that restrictions will only prevent safe abortions, not the act itself.
"This is a devastating blow, and my patients know it," Dr. McHugh said.
A path forward
Once Indiana enacts its abortion ban in September, Dr. McHugh will transition back to the full scope of her OB-GYN practice and help transfer patients seeking abortion care out of state. She is also getting licensed in other states so that she can continue to include abortion care in her practice by traveling or through telemedicine.
"The idea that OB-GYNs will just sort of allow our patients to die in front of us because we are worried about a fine is laughable because none of us would allow that to happen," she said. "Now there may be delays; there may be concerns. There may be consultations with legal, but we will intervene and try to save a patient's life or transfer them to someone who can before we just watch someone die in front of us at the risk of our own personal safety and financial freedom."