by Megan Burbank

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Last summer, when the U.S. Supreme Court revoked the right to an abortion through Dobbs v. Jackson Women’s Health Organization, speculation swirled as to how the decision would impact abortion access. But it was difficult to capture meaningful data in the immediate aftermath: Abortion rates shift seasonally, and they were already on the rise in states like Washington in the years before Dobbs, largely because of restrictive abortion laws that have propagated throughout conservative-controlled state legislatures since Roe v. Wade was first decided.

Now, emerging data on the fallout from Dobbs is getting clearer: What was already a national crisis in maternal health among Americans has been catalyzed by the loss of Roe, according to physicians responsible for providing pregnancy care across the country, both in states with abortion bans and broader access to care. From March 17 to May 18, health policy organization KFF surveyed 569 obstetrician-gynecologists about their experiences after Dobbs and released the results of its national survey on June 21. Here are the major takeaways from the report — and what they could mean for the Pacific Northwest.

Even in states with protective abortion laws, institutional policies are keeping OB-GYNs from providing abortion care.

Though it’s clear that state-level abortion bans have disrupted abortion care nationally, abortion access is at issue even in states without these laws. According to KFF’s survey, among OB-GYNs in states where abortion remains legal, 80% either provide abortions or refer for them. When asked to give a reason for not providing abortions, 40% reported that the practice or institution that employed them had “a policy against performing abortions for pregnancy termination.” A similar share of their counterparts in ban states (42%) said the same.

Notably, in states that have upheld abortion access, 48% of providers who do not perform abortions also said the service was “readily available in other locations nearby.” But the 40% who reported that their workplace bans the practice aligns with the prevalence of religiously affiliated hospitals throughout states like Washington. Even with Roe in place, and now, with Washington’s robust state-level protections for abortion care, many religiously affiliated institutions in the state — and hospitals that have merged or established operating agreements with them, like Swedish and Virginia Mason — have stopped providing elective abortions. Some theoretically make exceptions to this rule in emergency situations where an abortion is required, and state law protects providers who perform abortions under these circumstances. But even with these policies in place, it’s unclear how often exceptions are made, and the dynamic reflects the concerns of Washington OB-GYNs’ counterparts in ban states, where poorly defined exceptions for abortion don’t expand access but rather sow confusion and concern over legal ramifications of providing care.

In states with abortion bans or ambiguous state policies criminalizing facilitating abortion, OB-GYNs also are less likely to provide referrals for abortion.

In states with abortion bans, the OB-GYNs KFF surveyed reported they were not just less likely to provide abortion, but also more inclined to share “information resources about abortion (e.g., a link to Abortion Finder or Plan C) than make referrals,” even though out-of-state travel is increasingly the only way people living in ban states can access treatment. 

The report attributes this not just to abortion bans, but also to ongoing ambiguity introduced by policies in some states. “This is not surprising in light of confusion in states like Idaho and Texas regarding the legality of abortion referrals,” the report’s authors write. In Texas, the report attributes this lack of clarity to Senate Bill 8, whose ban on “aiding and abetting the provision of abortions” disincentivized abortion referrals among providers.

In Idaho, the confusion stems from a letter the state attorney general issued in March saying that referring patients to other states for abortion was illegal; he later rescinded the letter after being sued by Planned Parenthood Great Northwest, Hawai‘i, Alaska, Indiana, Kentucky. But amid the ongoing patchwork status of abortion rights post-Roe, even the suggestion of illegality can introduce new confusion for both patients and providers. And in some cases, providers in ban states don’t even provide information about abortion: 30% of respondents said they did not.

OB-GYNs report a lower standard of care — and concerns that new restrictions are further entrenching long-standing health inequities.

While the physicians KFF surveyed raised concerns about legal penalties for providing abortions, they also reported other impacts on their ability to provide appropriate medical care, with 44% saying “their decision-making autonomy has become worse in the past year” and 36% reporting “their ability to practice within the standard of care has deteriorated.” They also reported worsened doctor-patient relationships. (While these concerns were heightened in states with near-total or gestational abortion bans, 23% of providers in states where abortion remains legal also said practicing within the standard of care was more challenging since the Dobbs decision.)

This applies not just to abortion care but also to pregnancy care, with 20% of OB-GYNs reporting limits on their ability to provide treatment for miscarriages and 19% reporting constraints on handling pregnancy complications. While the report links these limits to abortion bans, their impacts are likely to be felt even in states like Washington: If a pregnant person can’t receive care for a miscarriage in the state where they live, they may be forced to travel; a previous national report documented this exact scenario.

The ramifications on an individual level are clear: Patients experience delays in treatment, and doctors express concern about legal ramifications for providing treatment that meets the standard of care. But in the long view, this is likely to deepen health inequities already contributing to an increase in the United States’ maternal mortality rate, which is disproportionately high among Black birthing people. In Washington, birth justice activists have fought for Medicaid coverage of doula support as one way of counteracting this dynamic, but such policies are unlikely to advance in states that already have gutted access to basic abortion care and appropriate treatment for pregnancy complications and miscarriages. As they have for years, states like Washington will likely end up accommodating this influx of patients, now traveling more frequently for reasons beyond elective abortion.

While KFF’s survey of OB-GYNs focused on these detrimental impacts, it did identify one area of change that could potentially expand access: 69% of providers surveyed now provide “at least some care via telehealth.” The report attributes the increase to COVID-19, which also prompted loosened restrictions on the distribution of abortion pills by mail. In some states, this remains an option for patients seeking treatment within 11 weeks of pregnancy, and several websites provide clinician-assisted medication abortion via telehealth, with some of them, like Aid Access, operating within a legal gray area — a dynamic that allows them to skirt the legal constraints that OB-GYNs providing abortions within the medical system now face.

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📸 Featured Image: Photo via Sheila Fitzgerald/Shutterstock.com

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