How Institutions Can Support Ob/Gyns in Abortion-Restricted States

To better understand the ramifications of the Dobbs decision on clinical practice and on ob-gyns more personally, Kavita S. Arora, MD, MBE, an ob/gyn at the University of North Carolina at Chapel Hill, and colleagues interviewed 54 ob/gyns in 13 of the 14 states with near-total abortion bans.

Their qualitative study, published in JAMA Network Open in January, captured the depression, anxiety, and moral distress that ob/gyns experience in abortion-restricted states. One physician reported a fear of their actions being deemed a crime that was so visceral that they began dry heaving in the operating room.

Arora and her team also found that institution-level practices could mitigate or magnify the impacts of abortion bans on physicians’ health, well-being, and commitment to their profession. These findings ultimately led them to develop a “playbook” to support ob/gyns in abortion-restricted states, which they published as a Viewpoint in JAMA.

This interview has been edited for brevity and grammar.

When did you first realize the significance of the Dobbs decision on ob/gyns, particularly in red states?

Arora: After the Dobbs decision leaked in May 2022, the impact on ob/gyns was immediately palpable. There were lots of tears. Many clinicians worried about a future in which they would not be able to provide comprehensive care to their patients. In June 2022, those fears were realized.

What was the take-home message from your original study?

Arora: The most important impact that needs to be studied of the Dobbs decision is the impact on patient care. But clinicians who have to bear witness to the pain and suffering of patients, and to practice medicine in a way that goes against the oaths that we took, are essentially “second victims” here.

After the Dobbs decision and the wave of abortion bans that followed, clinicians were obligated to wait for legal teams to approve their clinical decisions, to ensure that their actions counted as medical exceptions to bans, which delayed care. Some could no longer counsel patients on evidence-based options for pregnancy health or make referrals. They lived in fear of violating the law and being reported. By 2023, some had already packed up their practice and moved to another state. Those that stayed reported feelings of depression and anxiety, as well as moral distress.

Was there one particular interview story that stood out to you?

Arora: I think the narrative of the clinician who had been in practice in their small town for a long time and had to leave.

I can’t imagine being put in a position of deciding whether I would end up in jail for continuing to provide the care that I swore an oath to provide, or uphold my duty to make sure that my kids had a mom who wasn’t in jail, that there was food on the table, that I took care of employees whom I promised a paycheck. All of those things are really, really hard to weigh.

Let’s talk about the “playbook” for institutions who want to better support these ob/gyns and keep them in practice. What is the most important thing these institutions can do right now?

Arora: It is a really hard thing to be a risk manager, or a lawyer, or a leader of an institution, and have to make a decision of whether to risk the institution for providing care to one patient or a small subset of patients. And clinicians feel the same tension of, “Do I provide care to this one patient and risk going to jail, and my ability to provide care to patients and the community in the future?”

So, I think the most important step institutions can take is acknowledging that discomfort. In our interviews, when clinicians felt like they had to fight against their institution, that caused more burnout and more stress than in places where clinicians felt like they were supported.

You and your co-authors also recommend having guidance for ob/gyns who have patients who may require abortion care.

Arora: Certain conditions are more commonly going to bump up against an abortion ban than others. So, institutions can make a list that says, “For conditions X, Y, and Z, our legal team feels confident in arguing that this would fall under the exception. Go ahead and provide care and document it as such. And these other conditions are a little bit more nebulous. Please call us.”

That level of granularity is really helpful. Even if an institution is unwilling to put that in writing, simply having a meeting and talking through these scenarios is incredibly powerful.

Nobody wants to be taking care of a patient at 2 a.m., who’s had an awful outcome and is deciding between two awful choices and not know whether those choices are legal.

You also recommend institutions provide legal representation for ob/gyns and 24/7 access to legal counsel. Can you expand on this?

Arora: This is uncharted waters. Some criminal lawsuits take years of time and millions of dollars, and hospital resources are not set up to provide this, which is why I think the idea of forming teams across regions — an idea that came out in our interviews — made a lot of sense to us. Should something awful, but rare, like a criminal case, go forward, but also much more for the everyday things, such as the 2 a.m. phone calls.

Lastly, your Viewpoint calls for institutions to support ob/gyns to provide abortion care out of state. Why is that important?

Arora: In the part of North Carolina where I practice, we have many fellowship-trained family planning providers. After Senate Bill 20 passed (banning most abortions after 12 weeks), many of these providers began getting licensed in Virginia and traveling there to provide care, where there’s now an influx of need.

So, I think institutions can help defray the cost of licensing in other states and the cost of travel to other states, recognizing that this evidence-based healthcare continues to be part of the mission for that institution of providing care, within the clinician’s skillset and within what is deemed standard of care by national organizations.

Because you are an ob/gyn practicing in a state where abortion is restricted, you can easily put yourself in the shoes of the people you interviewed. Do you think others understand how difficult this is?

Arora: When I explain it to people who aren’t ob/gyns, I compare it to the tension clinicians felt in early March of 2020 when we didn’t know what COVID was, when there was not enough personal protective equipment, and we were asked to run into this burning house without adequate protection.

Previously, the ethical guidance of medical organizations implied that healthcare workers have an above-normal duty to others, especially in a crisis. Since the pandemic, many organizations, including the American College of Obstetricians and Gynecologists, have revised those policies to now say that the social contract is bi-directional.

Society also owes protections to their healthcare workers. It can’t expect the healthcare team to run into a burning building without protection. The social contract also doesn’t mean going to jail to provide good care for our patients.

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