By the time I had started my ob/gyn residency, Roe v Wade had been the law of the US for 15 years. I never knew a world where patients attempted to end a pregnancy by themselves or in a back alley clinic. When I graduated from residency in 1991, the world of healthcare for women was rapidly changing and improving. Over 50% of residents were now women, the first residency to see that change. Ultrasound capabilities were rapidly changing; we could diagnose an ectopic pregnancy before the tube ruptured and identify fetal anomalies at 20 weeks, when women still had a choice in whether to continue their pregnancies. Contraceptive options were become more than just the pill or condoms. Minimally invasive surgery technology was in it’s infancy but we all understood how it would dramatically change our future careers. Reproductive options were expanding for infertile couples. It was an exciting time to be part of women’s healthcare. 30 years later as I am winding down my career, I am frustrated that we are suddenly losing so much of what we have gained. Now only will healthcare for women suffer, but the training of new ob/gyn physicians will also deteriorate.
Attracting medical students to consider a career in ob/gyn has always been a bit difficult due to high malpractice costs, work hours and caring for only women. Now, more than 90% of ob/gyn residents are women and most are at a time in their life when they are starting families or have young children. Our profession is one of the few that still involves both office and call schedules, rather than shift work. It is a delicate balancing act that is often worsened with sleep deprivation. In states where abortion is now illegal, that work burden will become even heavier when caring for pregnant women with complicated pregnancies; partial miscarriage, ectopic pregnancies, lethal fetal anomalies, second trimester rupture of membranes. Many medical students will decide not to choose a career in ob/gyn due to one or more of the above risks that are unique to our profession.
And then there are the politicians and Attorney Generals. The AG of Indiana recently called out the young female physician who provided abortion care to a 10 year old pregnant child. Previously she had quit working at Planned Parenthood when there were credible kidnapping threats around her daughter. Her entire career could be destroyed by one man. Politicians have wrongly stated that ectopic pregnancies can be reimplanted in the uterus or that there is no risk to a 10-14 year old to carry a pregnancy. Combating these falsehoods while also worrying about risks to family/self and accompanying lawsuits is a scenario many women will not choose for their workplace atmosphere.
Abortion has always been legal while I have been in training or practice. I took that for granted until I started to travel to Haiti for medical mission work in 2006. It was there that I saw the consequences of illegal or self inflicted abortion – women who died of uterine infections or lost their reproductive organs due to uncontrolled bleeding. In the larger cities, entire wards were devoted to the care of these women. Emergency rooms in states that have outlawed abortion will soon start to see some of these very same cases. Unlike my Haitian colleagues, US physicians are ill adapted to know how to treat these complications and may waver in their care as they worry about the legal implications. Worse yet, some may be obliged to report a women who has obtained an illegal abortion.
Maternal mortality is already highest in the states that have chosen to make abortion illegal.
- Louisiana (58.1 per 100k)
- Georgia (48.4 per 100k)
- Indiana (43.6 per 100k)
- New Jersey (38.1 per 100k)
- Arkansas (37.5 per 100k)
- Alabama (36.4 per 100k)
- Missouri (34.6 per 100k)
- Texas (34.5 per 100k)
These are also the states where it is more difficult to obtain inexpensive birth control or access to comprehensive sex education. Ob/gyn residency programs in these states will be handicapped as potential candidates preferably seek education in states where abortion remains legal, maternal mortality is low and women have more access to birth control so that pregnancies can be planned.
The governing body of The American College of Ob/Gyn is located in Texas. In order to obtain board certification, every Ob/Gyn has to travel to Texas 2-3 years after finishing residency to take an oral board exam. That exam was made virtual during Covid and was supposed to resume in person this year. Due to an outcry from many in our profession, the exam will remain virtual for the foreseeable future. If our own governing body does not think Texas is a safe place for women, what does that say for the future of women who might wish to practice in those states.