Dobbs Has Fundamentally Changed Obstetric Care, Study Finds

Abortion bans continue to impact how clinicians provide obstetric and other medical care, according to a qualitative study of 86 clinician narratives.

After the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision overturned Roe and eliminated federal abortion protections, 24 states placed restrictions on abortion, with 20 of them having total bans or bans starting at 6 weeks’ gestation. In the wake of these bans, many hospital systems and employers told clinicians not to speak to the media.

The research group Advancing New Standards in Reproductive Health (ANSIRH), based at the University of California San Francisco, launched its Care Post-Roe study in September 2022, aiming to “provide a venue for healthcare providers to anonymously share information about cases of poor-quality care due to new restrictions on abortion.”

These clinician narratives are a continuation of that study, and of the cases described, 63 occurred in the first year post-Dobbs, but 23 occurred since July 2023, with several even occurring last month, reported Daniel Grossman, MD, of ANSIRH and UCSF, and colleagues.

“We’re continuing to see these cases of poor-quality care more than 2 years after Dobbs,” Grossman told MedPage Today. “I really am now coming to believe that these laws are just incompatible with evidence-based medical care, and the bans need to be repealed — and that’s the only solution.”

ANSIRH’s report includes specific patient scenarios and clinician quotes from the submitted narratives. One narrative details the case of a patient who had preterm premature rupture of membranes at 16 to 18 weeks but was denied an abortion due to state law and sent home. She returned to the hospital 2 days later with severe sepsis and bacteremia.

“The anesthesiologist cries on the phone when discussing the case with me — if the patient needs to be intubated, no one thinks she will make it out of the OR [operating room],” the clinician said. Ultimately, they performed a dilation and curettage on the patient, who “miraculously” survived. Prior to Dobbs, the standard of care would have been to immediately offer the patient the option of a dilation and evacuation or induction termination.

Most of the narratives fell into nine categories:

• Obstetric complications in the second trimester before fetal viability
• Ectopic pregnancy
• Underlying medical conditions that made continuing a pregnancy dangerous
• Severe fetal anomalies and fetal compromise
• Miscarriage
• Extreme delays in obtaining abortion care
• Intersection with the carceral system
• Difficulty obtaining post-abortion care
• Delays obtaining medical care unrelated to abortion

Authors noted that between April 2023 and August 2024 they “received at least one (and generally more than one) narrative that fit into each scenario category, suggesting these cases have continued to occur and were not limited to the immediate aftermath of Dobbs.“

When they began the study, Grossman and team wondered if clinicians would find workarounds despite restrictions. In MedPage Today‘s own survey of healthcare professionals who handle reproductive care practicing in abortion ban states, 60% reported finding workarounds to get patients the care they needed.

Some states have made efforts to clarify their abortion laws and provide guidance on how to perform legal abortions when a patient’s life is at risk. However, “rather than increasing clarity and identifying workarounds over time to provide evidence-based care, our findings suggest that the abortion bans have fundamentally altered how pregnancy-related care — and even other medical care for people with the capacity for pregnancy — is delivered,” authors concluded.

Grossman observed that “moral distress is now incorporated into medical education, with medical students and residents essentially learning about this moral distress as part of their training.” For instance, they learn the correct way to manage their patient, but also know in some cases they could be prevented from offering that care and instead have to watch their patients suffer. Despite media coverage, Grossman said that he feels like “people still don’t realize that these bans are having a broad impact on obstetric care.”

Researchers solicited narratives by posting on listservs, forums, and social media accounts that target healthcare providers. After submitting a narrative, participants had the option to participate in an in-depth interview, though the findings of the interviews are not included in this report. Of the 86 narratives, 33 participated in in-depth interviews and five requested an interview outside the online submission platform. Audio and written submissions were accepted from September 29, 2022 through August 16, 2024.

Obstetric complications in the second trimester were the most common theme (n=24), followed by ectopic pregnancy (n=14), fetal anomaly or fetal compromise (n=13), and miscarriage (n=12). Most patients were between 18 and 35 and spoke English; 40% of patients were white, 23% were Black, 19% were Hispanic, 5% were Asian, 3% were multiracial, and 10% had missing race information.

Grossman said the study had a few limitations, including its qualitative nature, and researchers can’t determine how often these deviations from the standard of care occurred. Plus, all the data are from the perspective of a clinician — including patient race and ethnicity data.

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