OB-GYN Training and Practice in Dobbs’ Shadow

When Rachel Jensen applied for a fellowship in complex family planning at the University of North Carolina, Chapel Hill, in the spring of 2022, she knew that the U.S. Supreme Court was likely to overturn the federal right to abortion in its upcoming decision in the Dobbs case.

By the time she was accepted to the program, Dobbs was in place, and the state had reinstated a decades-old 20-week abortion ban, which was ruled unconstitutional in 2019. After she arrived, the state scaled that back further, issuing a near-total abortion ban after 12 weeks’ gestation.

In the wake of Dobbs, 14 states have fully banned abortion, and another three have banned it after six weeks’ gestation. But complex family planning is an OB-GYN specialty that involves caring for patients who need later-stage abortions for a range of reasons: They may discover health complications, for example, or lethal fetal anomalies well into the second trimester, or later.  

The state’s restrictions mean that Jensen has to travel to Virginia to get the practice she needs to do the work. They also mean that providers are having to jump through hoops to get patients care they can’t provide, referring them to out-of-state clinics and organizations that can help with transportation and other costs.   

As for staying in the state to practice, the hurdles are a significant consideration for Jensen. “It may not make sense professionally,” she says.

About half of OB-GYN programs are in states with significant abortion restrictions. A December 2023 study in the Journal of Law, Medicine & Ethics shows that post-Dobbs, abortion training gaps will exacerbate long-standing health disparities in reproductive health, diminish clinical skills and knowledge in abortion care, and lead to a rise in complications and maternal mortality. This is especially true in rural areas also suffering from hospital closures and health care access gaps.  

More than 2 million women of childbearing age already live in so-called maternity care deserts—the 1,052 U.S. counties with no obstetric providers and no hospital or birth center offering obstetric care. In the wake of Dobbs, dozens of abortion clinics closed across the U.S. And amid post-Roe abortion bans and restrictions, the proportion of patients traveling out-of-state for abortion care has doubled from 1 in 10 in 2020 to 1 in 5 in the first half of 2023. Those who can’t travel may forgo abortion care altogether, resulting in unintended births, which have also increased after Dobbs, or be forced to rely on providers who can’t—or won’t—give them medically accurate and complete information about their options.  

But the impact is broader than OB-GYN care. The vast majority of physicians and trainees in all specialties prefer to practice or study in states with abortion access, according to a 2023 report in the Journal of General Internal Medicine. Trainee physicians, most of whom are of child-bearing age and deciding where to plant their roots, are making their choices based on where jobs are available, where they can best provide care, and where they can get it for themselves and their families.  

That reality paints the bleak forecast for health care staffing, says Benjamin Thornburg, a PhD candidate in Health Policy and Management who is studying the long-term impacts of Dobbs. 

“There tend to be [health care] shortages in states that have bans already.” If medical students avoid applying to residency programs in ban states, “downstream the shortage areas get worse and worse,” they say. 

I have colleagues across the whole country emailing me about opportunities for their residents to seek training out-of-state with us.

Although applications to OB-GYN programs in ban states were down 10% last year compared to the previous match cycle, the specialty remains in demand, and residencies in restrictive states are still filling up. “But how many of those providers will actually be performing abortions?” wonders Joanne Rosen, JD, MA, a practice professor in Health Policy and Management who studies the impact of law and policy on abortion access.  

“We need to have succession planning” for this increasingly scarce and stigmatized workforce, says Rosen. “A sizable segment of abortion providers in the U.S. are older, and there has been concern for a while about getting younger, newer graduates in,” she says.  

Cross-state training programs between protective and restrictive states, like the one Rachel Jensen is involved in, are one solution—and, because the Accreditation Council for Graduate Medical Education requires access to abortion training for OB-GYN trainees, a necessary one. Such programs are already ramping up to help more students and cover more of their costs.  

But these programs have limitations, says Jessica Lee, MD, MPH ’17, assistant professor in Obstetrics & Gynecology at the University of Maryland School of Medicine and director of the university’s Ryan Residency Training Program, one of the programs offering cross-state support.   

“I have colleagues across the whole country emailing me about opportunities for their residents to seek training out-of-state with us,” she says. “But honestly, there's no great way to get that training accomplished because we still have to address the training needs of our current residents.” 

Lee also must consider how to use limited resources: “What does it mean to train a resident and provide one or two weeks’ experience—what are they going to do with that if they're not going to get to continue those skills when they return to their home program? It raises a lot of questions about how we invest our time.” 

One thing that brings her hope is that, galvanized by Dobbs, the current generation of medical trainees is deeply committed to ensuring that abortion care is available to their patients.  

Jackline Lasola, an OB-GYN resident at the University of California, San Francisco, has ruled out living in a ban state but wants to “find some way to provide services” in ban states, perhaps by working as a traveling provider. “That’s something that I’m open to in those types of places.”

When it comes to abortion access, the current crop of trainees is “200% more interested than medical students were five or 10 years ago, and I'm absolutely ecstatic,” says Lee. “This current generation is really fired up, and we’re lucky to have them fighting for our patients, regardless of what the future legal landscape looks like.”