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Commentary
How the fall of Roe could change abortion care in Mass.
On June 24, our profession, sense of self and American identities were shaken to the core by the Supreme Court ruling that overturned 50 years of legal precedent providing federal protections for abortion. As four obstetrician-gynecologists from academic medical centers in Massachusetts, we are fortunate to practice in a state in which the right to abortion is protected by statute.
However, living in Massachusetts will not completely protect patients or providers from the impact of this decision. We have been horrified by how this ruling has affected our colleagues in other states as they seek to provide care for their patients, and we are already feeling the impact of this decision in Massachusetts.
As a result of the Supreme Court decision, seven states immediately outlawed or severely restricted abortion care, and many others are expected to follow. The state laws, devoid of clinical scenarios and medical language, don't give providers clear guidance and are already harming patients.
The 2021 Texas law prohibiting abortion after six weeks had an immediate impact, delaying necessary care for pregnant people, which resulted in life-threatening complications for many patients. Many anecdotal reports suggest physicians in the states immediately impacted by trigger bans, now uncertain about the legal implications of vaguely-worded restrictions, are delaying emergency care until patients’ health dramatically deteriorates.
Where statutes do seem clear to health care providers, the predictable results of abortion bans have raised questions among even anti-abortion activists. The 10-year-old from Ohio who was pregnant from rape and forced to travel to Indiana to get the care she needed garnered national media attention.
[T]hese bans also have the potential to subject Massachusetts physicians who care for these patients to criminal prosecution, civil suits and public scrutiny.
While pregnant people from states hostile to abortion will suffer the most under these restrictions, these bans also have the potential to subject Massachusetts physicians who care for these patients to criminal prosecution, civil suits and public scrutiny. The Ohio case highlighted the risk to physicians who provide legal abortion care in their own states; the physician who cared for the unidentified child has been vilified in national media and by the Indiana attorney general.
Massachusetts Gov. Charlie Baker signed an executive order to protect health care providers who provide abortions and their patients by prohibiting cooperation with out-of-state investigations into legal care, among other measures. The legislature is currently working to pass comprehensive protections for patients and providers of abortion care through multiple measures, including through enhanced privacy laws. Although this legislation could shield physicians from criminal prosecution for abortion care legally rendered within the state of Massachusetts, it doesn't protect these physicians from potentially financially devastating civil suits filed by out-of-state private citizens.
Physicians also could remain vulnerable to prosecution if they perform a legal abortion in Massachusetts that results in a warrant related to that care in a state that has banned the procedure. Texas allows private citizens to target providers who provide abortions in violation of state law for a financial reward; this is of particular concern to obstetrician-gynecologists, who (prior to the pandemic) have to travel to Dallas to obtain board certification. Although the American Board of Obstetrics and Gynecology had planned to reinstate in-person certification exams this year, they recently announced that remote exams will continue, partially in recognition of the danger to physicians who provide abortion care.
Despite these dangers, Massachusetts-based reproductive health clinics and hospitals are working to increase capacity to meet the growing number of patients seeking out-of-state abortion care. While we are fortunate to have a centralized access system that is supported by the state, increasing the volume of care provided to patients will not be easy. We are in the third year of a global pandemic that continues to disrupt usual health care operations, and we face a historic shortage of health care workers.
Patients forced to travel for care will experience delays and likely seek help later in pregnancy, making medical abortion less accessible. A small number of providers are able to provide second-trimester abortion, compared to first-trimester procedures, which — along with the costs associated with later abortion care — further limits access for patients both in and out of state.
We fear a generation of OB-GYN residents will graduate without learning how to provide critical and potentially lifesaving care to pregnant people.
Finally, Massachusetts is a recognized leader in training the next generation of obstetrician-gynecologists, and as medical educators, we fear the impact of these abortion restrictions on current and future trainees. Since an anticipated 26 states are planning to ban or severely limit access to abortion procedures, nearly 2,600 trainees (44% of all active OB-GYN residents) will be unable to obtain critical experience at their home programs. Prior to the Dobbs decision, abortion training was a requirement for all accredited OB-GYN residency programs. Programs were required to “provide training or access to training in the provision of abortion care” to ensure that all residents graduated with the skill set to provide comprehensive pregnancy care; the medical and surgical care for abortion is identical to that for miscarriage management.
However, as a result of the limited access imposed by state-level restrictions, OB-GYN residency programs can no longer require this critical training. Program directors who want to provide comprehensive training to their residents will need to arrange training opportunities in states where abortion access is available and protected. In Massachusetts, many residency programs are working to arrange opportunities for out-of-state trainees while preserving the training of their own residents. However, it is unlikely that programs in states with abortion access will be able to fill the training needs. We fear a generation of OB-GYN residents will graduate without learning how to provide critical and potentially lifesaving care to pregnant people.
Much of the nation is reeling from the sudden loss of abortion access, but Massachusetts can be a beacon of reproductive freedom. As practicing obstetrician-gynecologists who provide comprehensive reproductive health care, we are grateful for a legislature that has been proactive in protecting abortion access, health care providers and all patients. As medical educators in a state rich in academic medical centers, we are committed to maximizing training in abortion care for resident physicians. As doctors who care for pregnant patients, we know the decision to end or continue a pregnancy is a deeply personal one. We are committed to doing everything we can to lessen the blow of the Dobbs decision and honor the decisions of pregnant people who seek care within the Commonwealth.
Megan L. Evans, M.D., MPH is an obstetrician-gynecologist at Tufts Medical Center and an assistant professor of obstetrics and gynecology at Tufts University School of Medicine. Erin Tracy Bradley, M.D., MPH is an obstetrician-gynecologist at Massachusetts General Hospital and an associate professor in obstetrics, gynecology and reproductive biology at Harvard Medical School. Luu Doan Ireland, M.D., MPH is an obstetrician-gynecologist and complex family planning specialist at UMass Memorial Medical Center and assistant professor of obstetrics and gynecology at UMass Chan Medical School. Chloe Zera, M.D., MPH is a maternal-fetal medicine specialist at Beth Israel Deaconess Medical Center and an associate professor in obstetrics, gynecology and reproductive biology at Harvard Medical School.
All authors are members of the Massachusetts American College of Obstetricians and Gynecologists executive committee.