On Dobbs: Our First Year of US OB/GYN Residency

We will never forget our first week of obstetrics and gynecology (OB/GYN) residency, how it began, Monday, June 20, 2022, with a nervous grip on a hysteroscope, and how it ended, Friday, June 24, 2022, with Dobbs and a walk to Planned Parenthood for a community rally. Standing at the starting line of the rest of our careers, watching the essence of our field change overnight, our perspective as the intern class of 2022 is unequivocally unique. Dobbs v Jackson Women’s Health Organization,¹  a landmark decision by the US Supreme Court that ruled the constitution does not confer a right to abortion, has indelibly changed our mindset, our training, and likely our futures.

The Dobbs ruling had been expected by the family planning community virtually since Roe v Wade,²  the 1973 US Supreme Court decision that initially upheld safe, legal abortion as a constitutional right. States with long-standing socially conservative legislatures, like our own, have been especially prepared for a total abortion ban by numerous not-so-subtle politico-legal attacks. According to the Guttmacher Institute, from Roe v Wade’s ruling to its reversal, 1381 restrictions on abortion were enacted by states, 46% between 2012 and 2022.³  These laws, often called targeted restrictions on abortion providers (or TRAP laws), include medically unnecessary restrictions, such as the minimum width that a hallway must be for an abortion facility to remain open. These laws were not meant for patient safety but rather to close clinics and make abortion provision as arduous as possible; and, clinicians who provide abortions have been taking note.

Although we were not blindsided by Dobbs, the ruling was still a collective gut-punch for many of us, an expected shock that is only now—a full 2 years later—wearing off. Now that the immediate shock is gone, we believe coordinated and precise action by the powerful medical and academic institutions that train and employ the physicians in this country is required. And, frankly, it is overdue.

Overwhelmingly, what we feel post-Dobbs is scared. We are training in Missouri, the first state to ban abortion post-Dobbs, meaning—by law—we can no longer provide evidence-based health care.⁴  Missouri bans all abortions, except in cases of medical emergency, which threatens the loss of license or felony charges for physicians in breach.⁵  Because the text of the law reads so punitively, it has struck fear into clinicians and caused life-saving care to be unnecessarily delayed or blatantly refused.

Shortly after Dobbs, a hospital in Missouri required pharmacists to approve use of misoprostol—a drug used in both postpartum hemorrhage and medication abortion—prior to its use in a hemorrhage.⁶  In a postpartum hemorrhage, a patient giving birth can lose 1 to 2 liters of blood in minutes. With no time for error, confusion over the purpose of a drug needed STAT can cause delays that kill people. We have stood at the end of a stretcher after delivery with one fist inside the uterus, one fist on the abdomen, trying desperately to tamponade the bleeding, frantically calling for medications and blood. And, yes, this is the type of scared we were expecting to be as OB/GYN residents. But, scared because our legislators—most of whom have never had the experience of being the responsible physician in a true emergency—have made laws about which medications are acceptable in this life-or-death circumstance, that’s a type of scared we were not expecting to be.

We have lost count of the patients transferred to our center for ectopic pregnancies with fetal cardiac activity. Ectopic pregnancies will never reach viability but can, untreated, rupture and kill the pregnant person. However, for physicians across the country, cardiac activity is proof of life, and the fear of being criminally charged with abortion is—while baseless—too compelling. Since Dobbs, we have anecdotally noticed that the frequency of hospital transfers for ectopic pregnancies has increased. This means that people with ectopic pregnancies are packed into ambulances for 4-, 5-, and 6-hour drives across the state to a few major centers, including our own, where they are immediately rushed to surgery to remove the pregnancy, and in some cases, the liters of blood that have already spilled into their abdomen.

In the winter of our intern year, we delivered the babies of those who could not access an abortion in the immediate aftermath of Dobbs. We have seen the state-sponsored forced births firsthand, and it’s like living in the world of the Handmaid’s Tale (a dystopian society in which women have no rights and are forced to have children for the good of society). This doesn’t make us scared—it makes us angry.

The above is a short list of examples of delayed or denied medical care in the wake of Dobbs, but there are hundreds more, many collected in a study by the University of California San Francisco.⁴  Most recently, not only are physicians at criminal risk for routine OB/GYN care, but patients have been charged for common, negative outcomes of pregnancy, including miscarriage.⁷  We are still struggling to match an emotion with this egregious precedent; however, shock, horror, and disbelief come to mind.

Nationally, data demonstrates an association between abortion-restrictive laws and poor maternal health outcomes.⁸  Maternal death rates from 2018 to 2020 were 62% higher in states restricting abortion than in states with retained access.⁸  Unsurprisingly, the 5 most dangerous states in which to give birth have seen complete abortion bans with few exceptions since Dobbs.^9-12  And, like Missouri, each has struggled with restrictive TRAP laws for decades.¹²  This is not a coincidence.

The cause of the correlation between dismal maternal mortality statistics and restrictive abortion legislation is likely due to several direct and indirect factors; however, a likely substantial contributor is the issue of access to care, as physicians choose not to train and work in states with punitive legislation for routine health care.¹³  Shortly after Dobbs, we are already seeing the chilling effect this precedent could have on health care access via a breakdown in the physician pipeline, starting with medical students.¹³ 

An Indiana study found that following Dobbs, 70% of medical students reported being less likely to pursue residency in a state with an abortion ban, and over half of students were less likely to pursue OB/GYN as a specialty.¹⁴  On a national level, data collected from the first residency application cycle post-Dobbs showed that the number of total applicants to OB/GYN programs fell across all states, and applications in states with abortion bans fell by significantly more, 10.5% vs 5.2%.¹⁵ 

For those choosing OB/GYN, training in complex family planning procedures remains essential. The Accreditation Council for Graduate Medical Education requires that opt-out access to abortion training be available to all OB/GYN residents.¹⁶  However, as of August 2023, more than 1100 OB/GYN residents are training in states with the most restrictive bans.¹⁷ 

As fewer applicants seek to train or build careers in states with abortion restrictive legislation, the gap in physician access between states will widen and lead to increasingly poor maternal outcomes.

As we look back at our first year as physicians, scared is not what we want to feel. We were hoping for empowered or inspired or passionate or, at the very least, to experience growth.

Should we fault ourselves for this feeling? Where have our academic institutions, state and national medical societies, hospital associations, and lobbying organizations been? Political posturing and shaking hands with elected officials on other reproductive health policies—“playing the long game”—has not been effective. When our institutions fail to speak up for medical integrity, individual physicians lose respect and trust.

Our OB/GYN intern class of 2022 is no longer optimistic. We are grounded in the reality that the state of reproductive health in our country will continue to suffer and probably worsen. We need our institutions to help us help our patients. We beg you. Speak up about abortion access, make public statements protecting choice, use your research dollars to bolster your family planning programs and OB/GYN departments, protect opportunities for trainees to learn essential medical skills, and use your collective lobbying, financial, and political weight to make policy changes. Because we, your residents, are drowning in the current reality of doing this work. And we are scared.