Dana Rector, a third-year medical student at Oakland University in Michigan, wants to become an ob/gyn. To do so, she’ll need to apply to and complete a residency program in the specialty, a process that’s more complicated now that the Supreme Court has overturned Roe v. Wade.
Rector has been thinking about those complications since September, when Texas passed a law known as the Heartbeat Act that made abortions illegal six weeks after conception and authorized state residents to sue practitioners who perform them. The law made her realize that finding the right program would be about more than just personal fit, but potential legal implications too.
“When I first heard about the Texas abortion ban, one of my first thoughts was, ‘I guess I know where I won’t be applying to residency,” Rector says.
Practicing ob/gyns and students like Rector who want to become one are facing new challenges under the new abortion reality, with millions of pregnant-capable people across the U.S. now without easy access to what has been a major part of reproductive health care. Following the decision, 13 states with trigger laws in place have either banned or are about to ban abortion access. Others are currently expected to take similar legislative action.
For many ob/gyns, abortion-related care is a small but essential part of their practice. To be unable to provide that care, as is now the case in nearly half the U.S., can be a key factor in deciding against practicing in those states at all—even as their expertise is needed in them more than ever because of an expected increase in births.
Will ob/gyn programs in banned states still attract applicants?
Becoming an ob/gyn, a doctor that specializes in pregnancy and female reproductive anatomy, requires training in abortion-related care from an accredited program, whose standards are set by the Accreditation Council for Graduate Medical Education (ACGME).
“Access to experience with induced abortion must be part of the curriculum in order to ensure that physicians in training have the opportunity to gain the experience necessary to care for all of their patients’ needs,” an ACGME spokesperson said in a statement. Individuals with moral and religious objections are allowed to opt out of the training.
Currently, 44% of soon-to-be certified ob/gyns are training at medical residency programs in states that have either banned or are expected to ban abortions, according to a recent study published in the journal Obstetrics & Gynecology.
Those residents, and all future residents, will now need to finish their training out of state—a fact that might dissuade applicants from applying to residency programs and later practicing in those states. Others, like Rector, say they won’t apply to those programs on principle alone.
A little over half of the time, medical students establish careers where they do their residencies, according to a 2021 study by the Association of American Medical Colleges. The majority of residents—55.5%—who completed their training from 2010 to 2019 still practice medicine in the state where they completed their residencies, the survey found.
“If we have trouble filling our program or people don’t want to train here, even if we can stay accredited without offering that care, then that will affect the workforce long term,” says Dr. Lisa Harris, an ob/gyn and professor of reproductive health at the University of Michigan.
Michigan has a law from 1931 in place that bans abortion except in cases where the life of the mother is at risk. However, a legal injunction means the ban is unenforced and that abortions are therefore legal in the state.
In November, Michigan residents will vote on whether to keep the state an abortion haven.
Rector, who is from Michigan, wants to start her career there. But she says that an abortion ban would make her likely to practice somewhere else.
“One hand tied behind your back”
Flora Martz, another third-year med student and prospective ob/gyn at Oakland University, said she also began to realize her options for residency programs were narrowing when Texas’ Heartbeat Law took effect last year.
Around the same time, her boyfriend, a software engineer, was offered a job in Texas. She says he ended up turning down the offer after the two had discussed the matter further. “When it comes time for residency, I’m not applying to any programs in Texas because that just doesn’t align with what my goals are,” she says. “At this point, I’ve gone to too much school to not get exactly the education that I want.”
More established ob/gyns sympathize with those who are just starting out in a field that has always faced heightened politicization. “I don’t think I anticipated that I was going to need a mini law degree to be able to do my job,” says Dr. Beverly Gray, the residency director at Duke University’s obstetrics and gynecology department in North Carolina.
That state is expected to maintain abortion access, though she says her hospital has already seen a surge in patients from states where care has been more restricted.
Gray says it’s easy to imagine the overturning of Roe impacting career decisions and influencing would-be ob/gyns to pursue other specialties. “Some people just want to work and practice medicine and not have to worry about whether they’re going to be prosecuted or whether they’re going to be harassed because of the work that they do,” she says.
Dr. Deborah Bartz, an ob/gyn at Brigham and Women’s Hospital in Boston, agrees. She expects medical students, residents, and even young faculty members to make career decisions based on the decision to overturn Roe. Many prospective ob/gyns, she says, won’t want to work under limits on them exercising the full scope of their training.
“It’s really hard to tell a professional to come into work and do your job, but you have to have one hand tied behind your back,” Bartz says. “Now we certainly have this brain drain where smart, compassionate individuals are going to recognize the limits of what they’re allowed to do within their state.”
Practicing ob/gyns are already leaving
Not only prospective ob/gyns, however, are making decisions about their futures based on a more restrictive legal environment.
Emily, an ob/gyn who requested anonymity due to safety concerns, moved to Texas after completing her residency because she wanted to bring her expertise to a region where she felt it was acutely needed. Because she had abortion-specific training while other ob/gyns in her area did not, she could perform procedures that would otherwise require more invasive care.
“Even though we weren’t doing abortions necessarily, we were evacuating the uterus in a setting of a fetal demise, or if a patient came in hemorrhaging and had a further along pregnancy that needed a rapid removal,” Emily says.
Without practitioners trained in abortion-related care present, those patients would have needed to undergo cesarian sections, a major abdominal surgery with longer recovery periods than uterine evacuation.
After Texas passed the Heartbeat Act last year, Emily left Texas to go to a state where abortion access is not threatened.
“I’m the breadwinner in my family and I need to not end up in jail, need to not end up being sued for providing medical care,” she says.
In states where abortions are banned, many patients who want the procedure will end up giving birth. In a paper in the New England Journal of Medicine published earlier this month about the immediate impact of Roe’s overturning, University of Michigan’s Dr. Harris cites recent unpublished estimates from economist Caitlin Myers and other researchers that 18% to 57% of women wanting to end a pregnancy in counties where travel distances for abortion care has increased will ultimately give birth.
That short-term increase in births will have an immediate trickle-down effect through the ob/gyn workforce.
“Requiring labor and delivery units to work over capacity will affect all birthing people, not just those who would have ended their pregnancy,” wrote Harris, adding that newborn care providers, neonatal ICUs, and pediatricians will all feel strain from an increase in births.
Adds Emily, the ob/gyn in Texas: “The residents within those states are ultimately going to suffer, and not only is there going to be a lack of abortion services within those states, there’s going to be a real lack of all reproductive health services. It’s going to be a bad time for patients in these restricted states.”
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