OB-GYNs could have solidified abortion as health care after Roe. They missed their chance

Reflecting on this first anniversary of the Supreme Court’s decision in Dobbs to overturn Roe v. Wade, I think first about the unconscionable health risks faced by pregnant people in states where abortions are now banned, when their pregnancies turn dangerous.

But the decision has also been a nightmare for physicians (mainly OB-GYNs) in those states. These doctors — not all of whom identify as “abortion providers” — are caught in the untenable position of choosing between properly caring for their patients and risking imprisonment if convicted of performing an unauthorized abortion. (In Alabama and Texas, they might face life sentences.) This situation has become so difficult for physicians and other health professional professionals that a new phrase is increasingly heard in OB-GYN circles in banned states: “moral distress.” But the story of abortion in America might have been different, if the medical profession in 1973 had taken women’s health care needs more seriously.

My colleagues and I have been collecting testimonies from doctors in red states who are in this bind for the Care Post Roe research project at the University of California, San Francisco. We have received anguished reports of care denied or dangerously delayed in cases of ectopic pregnancy, severe fetal anomalies which are expected to cause fetal death, preterm pre-labor rupture of membranes (known as “PProms”), and numerous other serious conditions that can occur in pregnancy. Prior to Dobbs, usually the standard of care in these situations — even in red states — was to quietly offer the patient an abortion, often using the euphemism “termination.” One unintended effect of the Dobbs decision has been to make more visible how many things can go wrong in a pregnancy.

Our Care Post Roe project has also received submissions from doctors in states where abortion remains legal and who have treated patients from states with bans, typically through arrangements made by their local doctors. I have been able to conduct follow-up interviews with some of these blue state doctors and I have been very moved by their efforts to care for what can only be termed medical refugees.

Taking care of these patients is not always simple. They typically arrive very ill and need emergency care. Their cases can involve numerous consultations with the doctors in their home states. Their treatment can burden already strained hospital resources, such as operating suites. The very fact that they are travelers can itself complicate their care, with return flight schedules dictating timelines. One doctor told me of a couple who had driven four hours from a neighboring state and who insisted they needed to return that same day to pick up a child from day care, even though the particular procedure the woman required usually took place over two days.

Though such care for these patients poses challenges, as one doctor told me simply, “We have to do this.” Residency programs in blue states have also arranged to train residents in red states in abortion care. This training too can be complex to implement, but it can be a transformative experience, as I was told by one such grateful young physician who traveled to receive the education.

This culture of solidarity and cooperation among red and blue state OB-GYNs is one of the few bright spots I have observed within the world of abortion provision in the past year. (The tireless efforts of reproductive justice activists to help low-income abortion patients with funding and travel logistics are another.)

But having studied the evolution of abortion care in the United States from before Roe to the present, I experience some frustration with this phenomenon as well. Namely, I cannot help thinking that if this level of cooperation among OB-GYNs with respect to abortion care had existed at the time of the Roe decision in 1973, we might not be in the predicament in which we find ourselves now.

When Roe occurred, the majority of the medical profession, including OB-GYNs, supported the decision. This was hardly surprising as medical professionals were those most likely to see the effects of illegal abortion, which caused deaths and injuries to so many.

But there was less support for those who provided abortion. Although many decent and well-trained doctors provided illegal abortions pre-Roe as a matter of conscience, it was the infamous “back alley butchers” of that time who shaped mainstream medicine’s view of abortion doctors. Abortion care was stigmatized, seen as something necessary — but not what “respectable” doctors did.

As a result, the period immediately after Roe was noteworthy for what did not occur: Abortion training was not mandated in OB-GYN residencies (this would take another 20 years), most hospitals did not establish abortion clinics, and the most relevant professional societies did not issue guidelines for abortion care, as would be expected for a new service in high demand. In the years right after Roe, about 1 million abortions took place annually, reaching a height of 1.6 million in 1990, and more recently, somewhat less than 1 million.

In short, abortion provision did not become integrated into routine reproductive health care. The vast majority of abortions since Roe have been performed in freestanding clinics. They have provided excellent care, but this system has furthered the isolation of abortion provision from the rest of medical institutions.

If 50 years ago the field of OB-GYN had not been so skittish about abortion and this care had been firmly entrenched in medical institutions, it is quite possible that abortion would have come to be understood — by the medical profession and the general public — primarily as health care and not as the most divisive issue in American politics. Perhaps the newly emerging religious right of the 1970s would have found another signature issue, as nearly occurred, around which to grow their movement, and Roe would not have been overturned.

To be fair, in recent years as legal abortion became increasingly imperiled, the American College of Obstetricians and Gynecologists has spoken out frequently and forcefully against political interference with abortion care, and in support of abortion doctors. For example, ACOG has strongly denounced the Dobbs decision and spoken in defense of Caitlin Bernard, the doctor who was persecuted by the attorney general of Indiana after publicly acknowledging she had done an abortion on a 10-year old from Ohio.

These efforts are important, but the fact remains that abortion is now on track to become illegal in about half of the U.S. — and it didn’t have to be this way.

Carole Joffe is a professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco. Her most recent book, co-authored with David S. Cohen, is “Obstacle Course: The Everyday Struggle to Get an Abortion in America.”