Reproductive health care access

[00:00:13]

RICK WEISS: Hello everyone. Welcome to SciLine’s media briefing on access to reproductive health care in the United States. I’m SciLine’s director, Rick Weiss, and for those not familiar with us, SciLine is a philanthropically funded, editorially independent free service for journalists and scientists. We’re based at the nonprofit American Association for the Advancement of Science. Our mission is pretty simple, it’s to help reporters like you get more scientifically validated evidence into your news stories. And that means not just stories about science but any story that can be strengthened with the addition of some science. Among other things, we offer a free matching service that helps connect you to scientists who are both knowledgeable in their field and are excellent communicators. Just go to sciLine.org and click on “I Need An Expert.” And while you’re there, check out our other helpful reporting resources.

One thing I want to note about SciLine as we start this particular briefing, is that we don’t generally focus on policy or politics per se. Our focus is on scientific evidence around issues in the news. So, you might wonder why we’re having a briefing on a topic that is so steeped in political and policy controversy today, involving as it does questions about access to abortion, contraception, reproductive health services more generally. And the reason, if it’s not obvious already, is that as we approach this weekend, the one year anniversary of the Supreme Court’s Dobbs decision, which upended federal right to abortion and turned the issue over to individual states, we know that many of you will be crafting stories on the topic, and what drives the news of course here is policy and politics but what we aim to offer today are research findings that can strengthen your stories. So, the various opinions that are sure to be covered are accompanied by some relevant research findings for consideration by your readers and listeners and viewers. So that’s our goal here today, and just before we start, let me go through a couple of quick logistical details.

We have three panelists who will make short presentations of up to about 7 minutes each, before we open things up for Q & A. To enter a question, either during or after their presentations, just hover over the bottom of your Zoom windows, select that Q & A tab, and enter your name, news outlet, and your question. If you want to pose a question to a specific panelist, be sure to note that. A full video of this briefing should be available on our website, probably by this evening, tomorrow morning at the latest and time-stamped transcript within just a couple of days. But if you want a raw copy of the recording more immediately, just submit a request, again through that Q & A box, and we’ll send you a link to the video before the end of today. You can also use the Q & A box to alert SciLine staff of any technical difficulties.

OK, to get started, I’m not going to take time to give full introductions of all of our speakers, their bios are on the SciLine website. I just will tell you that we will hear first from Dr. Alison Norris, who is a professor at Ohio State University and the co-principle investigator of the Ohio Policy Evaluation Network. She’ll be providing an overview of how access to abortion has changed following the enactment of restrictive policies in various states, some of which happened before Dobbs and some after. Next we’re going to hear from Dr. Kari White, an associate professor and the principle investigator of the Texas Policy Evaluation Project at the University of Texas Austin, and she’ll be speaking about how access to a whole range of reproductive healthcare services has changed following policies that restrict abortion. And third, we’ll hear from Dr. Jody Steinauer, an OB/GYN physician, as well as director of the Bixby Center for Global Reproductive Health at the University of California San Francisco and director of the residency training program in family planning there at UCSF. And she’ll be speaking about how medical education has been impacted by policies that restrict abortion and how those changes in education are in turn affecting the safety of women who are in need of medical care. And with those introductions, why don’t we get started. Over to you to start, Dr. Norris.

[00:04:42]

ALISON NORRIS: Thanks very much for the opportunity to speak with you all today. As Rick mentioned, I study abortion access in my region and in the United States. The Supreme Court’s Dobbs v. Jackson Women Health Organization decision was issued just over one year ago, overturning Roe v. Wade. With the decision, for the first time in 50 years, each state’s legislature can decide whether to allow abortion in that state. Immediately following the Dobbs decision, 9 states banned abortion completely, by March of 2023, 13 states had banned abortion.

Americans have a wide range of feelings about abortion, many of them are complex. Abortion in America is highly stigmatized, highly politicized, very common, and very safe. One in five American women will have an abortion in their lifetime, abortion is safer than colonoscopy, and more than 900,000 people have an abortion in the U.S. every year. People with all types of beliefs have abortions; conservative women, transgender people, young women. None are immune to contraceptive failure, or illness to the fetus or the pregnant person, or rape, and many people find that no matter what their beliefs, carrying a pregnancy to term is not something that they can go through with and so, they have an abortion. A research project called The Turnaway Study, illuminated that people who don’t get an abortion when they need one are more likely to be living in poverty, even years later. And they are more likely to remain living with a violent partner. I’m now going to show you findings from #WeCount, a project of the Society of Family Planning that I co-lead, that measures abortion utilization month by month, state by state, over the past year. We’ve collected monthly abortion counts from 82 percent of all abortion providers in the United States and we make estimates to account for those clinics that don’t share their data. For each state we compare the pre-Dobbs number of abortion to the post-Dobbs number of abortions to look at increases and decreases. And here are the headlines; in states with abortion bans, there were 66 thousand fewer clinician provided abortions in the 9 months since the Dobbs decision than would have been expected in states with 6-week bans during the months that those bans were in effect, 16,000 fewer abortions were provided by clinicians than we would have expected.

So overall, the Dobbs decision disrupted to date over 81,000 people seeking abortion, especially in states where abortion is banned. Some of these people likely traveled and obtained abortion in another state and indeed, in states where abortion was permitted, we see an increase of 56,000 more abortions as compared to pre-Dobbs. But if you do the math, 81,000 fewer abortions in states with bans on the one hand, 56,000 more in states where abortion is permitted, overall there’s still 25,000 fewer abortions in the U.S. in the 9 months post-Dobbs than would have been expected. In other words, the increases in some states is not sufficient to make up for the losses in other states.

I’m going to give you examples from two regions in the southern United States to see how this plays out state by state; the first is the South Central subregion, the swath of the country from Texas to Kentucky, and this is the most dramatic picture in the whole of the United States. On the left hand side is the number of abortions and then it’s per month, and you can see that in the months after are Dobbs decision, every single state in this region banned abortion and the number of abortions provided by clinic drops to zero. So, what happened to these patients? I’m going to show you the South Atlantic subregion, a little bit to the east, to give some context for the changes. So this is a much more heterogeneous picture. I’ll bring your attention to the gray line, Florida, which is Florida, one of the states that saw the biggest increases post-Dobbs. The green line is North Carolina, which also saw very big increases, and the yellow line, you see a drop in Georgia. This is one of the states that saw great losses post-Dobbs, a 6-week ban went into effect in July. And I’ll point out that the Texas, the brown line on the graph that I showed you before, had already experienced a 6-week ban and so already about 50 percent fewer abortions were being provided in Texas in our pre-Dobbs number. So, this is all an under estimate really of the total of losses. So, you can see that many of these states here in the South Atlantic subregion are trending upward and of note, Florida, South Carolina, and North Carolina, which all provide a lot of abortion to people in their own states and people coming from outside the state, are considering gestational bans and total abortion bans. And there will be huge impacts if these are enacted. Let me pull back a little bit for the entire United States, and look at the overall increases and decreases. Some of these states we’ve already looked at and I just want to point out that in the places where they are increases, some of them have protected access to abortion, others don’t. They permit abortion, but the distinguishing characteristic amongst those with increases is that they’re geographically proximate to states that banned abortion completely. It appears that people are driving to the nearest states where they can get care. And again, the big takeaway is that the increases are insufficient to compensate for the decreases that we see.

I want to now show you data about abortion travel in the United States and I’m going to look at data from 2017, which is long before Dobbs. We assessed the policy environment of the state of residence of people who traveled for abortion and found that the likelihood of travel was associated with restrictions. The more restrictive the abortion laws, the higher the percent of people leaving the state. As you can see, people have needed to travel for abortion well before Dobbs. The majority of people who travel are traveling from states with restrictive laws and more than half of those who leave a state with restrictive laws went to another state with restrictive laws. This makes sense given that states with restrictions are in geographic proximity to each other. And this picture creates a house of cards in the post-Dobbs era; as states lose access, patients have to travel further and further, and as we see states ban abortion, those who need to travel experience these burdens inequitably. The barriers are greatest for people who are young or otherwise structurally disadvantaged by poverty and racism. People who aren’t able to travel for abortion care are those who are unable to get the resources to travel, including time. And those who are most unlikely to travel for an abortion are those who experience the same structural disadvantages that make them more likely to have unintended pregnancy and most need an abortion.

Following the Dobbs decision we estimate that 25,000 people appear not to have traveled for an abortion. What happened to them? Some of them will have self-managed their abortion by buying pills on the internet. While self-managed abortion is usually very safe, many people would not like to manage their healthcare by doing something they worry might be illegal. And many other people will have stayed pregnant and had a baby they did not intend to have. The final point I want to make is about the idea of abortion care churn. As state laws and policies change rapidly within states, it creates a sense, an experience of uncertainty.

I’m going to show you a series of maps that colleagues in my research group, the Ohio Policy Evaluation Network, created. The states are color coded by the gestational limit on abortion in that state, and I’m going to show you the changes that we experienced in the region week by week. This map is from just before the Dobbs decision. On July 1, 2022 you see dramatic changes, as states had bans and limits that went into effect at the time of the decision. And then these laws began to be challenges in state courts and new laws were enacted, and so you’ll see the progression. The point of these slides is how changing it is; July 6, July 14, July 21, August 3, August 26, September 16, I’ll stop here at September 23. As you can imagine, this rapidly shifting legal environment causes a huge amount of confusion for people who need abortions, for healthcare providers, the clinics themselves, and even people like me, trying to stay current with the laws. This final slide has links to the research studies that I’ve cited today. Thanks very much.

[00:13:15]

RICK WEISS: Thank you, Dr. Norris, for a really great introduction. Data rich there. I’ll remind reporters, these slides will be on display soon after so you can take a closer look at them and sort of harrowing look of how much more confusing things are likely to get as these changes continue. Why don’t we move on now to Dr. White.

[00:13:49]

KARI WHITE: Hi, I’m Kari White. I’m at the University of Texas at Austin, where I lead the Texas Policy Evaluation Project, and I’ll be discussing some research related to the impacts of abortion bans on pregnancy related care. Even before the Dobbs decision, the United States had very poor indicators of maternal health relative to other wealthy nations and particularly maternal mortality rates were high in states that were considered likely to ban or restrict abortion. According to a recent analysis of data from the Centers for Disease Control and Prevention, states that were likely to ban or restrict abortion, which are shown here on this graph in yellow, had higher rates of maternal mortality than states where abortion was likely to remain legal, which are shown by the green bars. Overall there were 24 maternal deaths per 100,000 births in the states that were likely to ban abortion compared to 16 maternal deaths per 100,000 births in states where abortion would likely be legal. And this pattern was consistent across different racial and ethnic groups but it’s also notable that the maternal mortality rates for non-Hispanic black and non-Hispanic American Indian and Alaska Native breathing people were more than 2 times higher than that of non-Hispanic whites. And so reflecting on the points that Dr. Norris mentioned about the populations that are going to be most affected by abortion bans, we can see that some of these are populations that already have very poor indicators of maternal health. And we can expect these indicators to look worse following the Dobbs decision.

While many states that have banned or restricted abortion have exceptions that allow abortion to be provided under certain circumstances, these exceptions vary across states. According to a recent analysis of state abortion laws conducted by KFF, of the 17 states with bans on abortion at 15 weeks of gestation or less, all of them have exceptions for instances where the life of the pregnant person is at risk, 11 have exceptions when the pregnant person’s health is at risk, and only 3 have exceptions for life-limiting fetal anomalies. However, the language that is used in these bans is often vague and not consistent with medical terminology and I can talk more about that in the Q & A, but it’s important to note that this vague language then makes it difficult for healthcare providers and their legal counsel to figure out how to practice in these banned settings and provide care to patients when they need it. So to capture some of the ways in which these abortion exceptions, or lack thereof, are practiced in states with abortion bans, my colleagues and I at the Texas Policy Evaluation Project, along with our collaborators at the University of California at San Francisco, have conducted several studies to look at how healthcare providers and patients are experiencing these bans.

What we have seen in our research is that abortion bans have compromised evidence-based care for pregnant patients. Clinicians practicing in states with abortion bans have found it difficult to provide the standard of care for patients who are experiencing obstetric complications such as pre-term, pre-labor rupture of membranes, or when the bag of waters breaks before the fetus is able to survive outside of the womb on its own. For patients who have medical conditions, like severe hypertension that make continuing their pregnancy dangerous, patients with severe fetal diagnoses, or when one twin in a pregnancy has died. Although ectopic pregnancy and miscarriage are often exempt from abortion bans, we have also received numerous counts from healthcare providers, as well as patients, who were unable to get the standard of care for these conditions as a result of the abortion bans. So to provide some examples of the types of information that we are getting in our research, I want to highlight a couple of our studies; one is the Care Post-Roe study that my colleagues and I have carried out with our collaborators at UCSF, and this study offers an online platform where healthcare providers can anonymously submit descriptions of care that deviated from the usual standard due to laws restricting abortion that went into effect after Dobbs. We received 50 submissions of these types of cases between September 2022 and March 2023. The patients that were described in these narratives that we received lived in one of the 14 states that, at the time, had banned or restricted abortion following the Dobbs decision. And those states are shown here on this map with the crosshatch markings.

I’m going to highlight just one of the examples that we received from our submissions, but data collection is ongoing. What we heard consistently through the interviews and submissions that we received is that patients frequently need to be sicker before providers can intervene and give them care. In one of the submissions that we received from a physician about a patient who experienced pre-term rupture of membranes, the physician wrote: she was admitted to the Intensive Care Unit from the ER with severe sepsis, which is a life-threatening infection, and bacteremia. Her fetus delivers, she’s able to hold the fetus, and we try every medical protocol we can find to help her placenta deliver and none are successful. 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 operating room. I do a dilation and curettage and she bleeds from everywhere, which is not the typical course for this procedure. The patient does survive and when she recovers she asks me, could she or I go to jail for this or did this count as life-threatening yet?

My colleagues and I at the Texas Policy Evaluation Project have also interviewed designs of pregnant patients who had medical complications and other patients who were pregnant and were unable to get an abortion that they needed. What we have heard consistently through these interviews is that patients feel lost and scared. One of the Texas patients that we interviewed who received a fatal fetal diagnosis, describes her inability to get information from her healthcare provider as follows: When you already have received news like that and can barely function, the thought of then having to do your own investigating to determine where to get this medical care and to arrange going out of state feels additionally overwhelming. Another patient who we interviewed who was unable to get the abortion that she wanted was very aware of the poor indicators of maternal health in Texas, and she said to us: I’m also scared to die. There’s a lot of complications and I’m starting looking into how like Texas isn’t that great when it comes to maternity care and stuff like that, at least from what I’ve read. I don’t know if the statistics have changed, but a lot of women die here during childbirth and so that is something that I’m really concerned about. So we anticipate that maternal health and indicators of severe maternal morbidity and mortality will become worse following the Dobbs decision because providers are unable to deliver standard evidence-based care to their patients.

To learn more about our study results and stay up to date on our findings, you can find our contact information for the Texas Policy Evaluation Project and the Care Post-Roe study here. Thank you.

[00:21:39]

RICK WEISS: Thanks Dr. White. Some amazing tales there of the ripple effects that a lot of people might not think about as we think about these legislative changes. Let’s move on to our third speaker, Dr. Jody Steinauer.

[00:21:57]

JODY STEINAUER: Wonderful. As you heard, I am an obstetrician gynecologist based in California, at UC San Francisco. I also travel to Kansas where I provide abortion care and have firsthand experiences of taking care of the patients who Kari described, whose stories Kari described. I’m going to focus my remarks today on the impacts of Dobbs on medical education, which includes medical school, residency, and for some, fellowship training. First, I will focus on medical school to emphasize the importance of educating all physicians who will interact with reproductive age people about abortion, even if they do not plan to provide abortion or miscarriage care. The Association of Professors of Gynecology and Obstetrics recommends that all medical students graduate with a deep and thorough understanding of abortion and are able to provide compassionate, non-directive pregnancy options counseling, including have the knowledge to explain abortion methods and their rare complications.

And I just want to emphasize that this basic education is so important. Physicians in all specialties and especially in specialties such as family medicine, internal medicine, pediatrics, and emergency medicine are often the first to tell a patient that they’re pregnancy test is positive and they must know how to refer to do this education, this counseling compassionately and how to refer abortion care, especially in states with bans. In addition, these physicians work in urgent care settings, and those in states with bans especially must know how to care for people who either self-manage their abortion outside of the formal medical system, for example, by accessing abortion care through online pharmacies, or who left the state to access abortion care. These patients may present to their primary doctors or in these acute care settings, with questions about bleeding or other symptoms and it’s important that these physicians are competent to provide this information and care and very important that they honor the patient’s confidentiality and to not report them to law enforcement. This is a map that you can find on the Guttmacher Institute’s website and it shows the states with the most restrictive bans are in dark red. Right now, just to give you an idea of how many medical students are being educated in these states, there are 30,000 medical students learning in these states who are at risk of not learning these basic skills because they do not have clinical exposure to patients seeking abortion care. After medical school, residency training is the part of medical education when the new physicians become competent in the skills required for their specialty. Abortion should be integrated in many residency training programs to ensure that graduates have the basic skills I mentioned before but it’s also the time when physicians learn the skills needed to do abortions. And while family medicine and other physicians can learn these skills during residency, I want to focus on obstetrics and gynecology, my specialty, which has unique obligations for abortion training.

So, all OB/GYNs must be competent in, to provide abortion care. Even if, even for those who do not plan to provide abortion care, we must, we are obligated by our profession to provide abortion care in the setting of an emergency if no one else is available. And this is a requirement by the American College of Obstetrician Gynecologists, and it is—we also of course, have to provide care for people experiencing pregnancy loss. And that is why the Accreditation Council for Graduate Medical Education, in 1996, started requiring all OB/GYN programs to include abortion training. And I’ll just, I’ll go back to that for one second. The Accreditation Council is the body in the United States that governs all residency training. So this is a very important requirement that’s enforced by the ACGME. After the Dobbs decision last fall, the ACGME reaffirmed this requirement and now has this additional language, and I included references in my slides that you can, so you can read the full document by the ACGME if you’re interested. It now does specify that programs must provide access to this clinical experience in different jurisdiction where it’s lawful, if the program is in a state where it’s unlawful to provide abortion care.

So, state abortion bans mean that many OB/GYN residents are at risk of insufficient training to safely provide this critical reproductive healthcare, and I’ll say a little more about why it’s so important but in the states with current bans, there are more than one thousand OB/GYN residents being trained. I want to emphasize that these residents are not only they are at source risk of graduating without the skills they need to provide abortion care, they are also at risk of not having the skills to provide care for people experiencing pregnancy loss or also what we call miscarriage. So, in this table I show you some data that we published with the proportion of residents in routine, programs with routine abortion training and the proportion of residents in programs with optional or no training, and this is the proportion who feel competent in these aspects of early pregnancy loss. So, that includes, they’re more likely to feel competent if they have routine abortion training in early pregnancy loss counseling, in facilitating medical management of pregnancy loss, the different procedures that we use to manage pregnancy loss, two different types of aspirating the pregnancy and removing it from the uterus, and even more likely to feel competent to manage complications of early pregnancy loss. This is just one of the many examples I could give you about the benefits of training and why training is so critical for OB/GYN residents.

I also want to discuss the potential psychological and moral impacts of these laws, which of course is a conclusion when you’ve heard from the previous speakers. Moral distress is the emotional state that occurs when one is unable to carry out what they believe to be the ethically appropriate action, often due to external circumstances. And it’s been described in nursing and in medicine for a long time. And what we’re seeing now is that in many states, learners are experiencing this distress due to witnessing or being forced to participate in substandard care. And this distress can lead to burnout and long-term moral injury. And I worry this might lead to many, many leaving medicine, or my specialty of OB/GYN, and will lead to fewer people wanting to train and practice in restricted states and this of course could worsen the disparities that already exist in these states with abortion restrictions. We already have evidence that after Dobbs, fewer medical students who were applying to residency training in all specialties, applied to programs in restricted states, and I’ll say a little bit more about those who applied in OB/GYN but there is definitely a feeling that because these medical students are of the age where they might be trying to become pregnant, there’s a worry that they don’t want to be training, regardless of specialty, orthopedics, surgery, anything, in a state where if something went wrong with their pregnancy they would be trapped without the ability to make decisions. The American—when they looked at the data for OB/GYN applicants, they saw that overall about 5 percent fewer medical students applied in OB/GYN in general, but found that 10 percent fewer applied in states with abortion bans. So we really are seeing preliminary evidence that this is true, that fewer people want to train in states with abortion bans.

So, as we train our learners to meet the needs of future patients in this landscape, we have a, we’re all employing a variety of strategies, some of which I’ve listed here. I want to say a little bit about supporting residents to travel to obtain care, and I direct the Ryan Residency Training Program in Abortion and Family Planning, I have this map at the bottom of the slide showing in blue, the states where we have supported OB/GYN programs to integrate abortion training and the Ryan Program has been in existence for more than 20 years and we’ve supported over 110 programs to integrate abortion training. After, first after SB 8 in Texas, we started supporting Texas-based residents to travel out of state for abortion training, and we were able to support more than 50 residents to travel to different programs. As you can imagine, this takes a lot of effort and work and formal agreements and licensure requirements, takes between 6-9 months to set up these arrangements. So, we started working with programs on a different strategy and that is that individual programs can partner with programs, host programs, in less restrictive states so that they can facilitate many residents to travel and so far we’ve worked with 12 programs to establish these relationships and we have 56 programs in states with the most restorative bans right now. So, we have a lot more work to do, but it’s happening and so far, preliminary evaluation shows that it’s beneficial. Residents appreciate it and they learn the skills they need to provide care to future patients.

So, I will close by saying [inaudible] to say that abortion care is critical, as you all have heard from ethical, clinical, and public health perspectives, and now that states are allowed to ban abortion, physicians are being forced to provide care that is not evidence based or patient centered and violates our, the three principles of medical professionalism as defined by the Physician Charter on Medical Professionalism, and these are the principle of primacy of patient welfare, patient autonomy, and social justice. And we are being forced to provide substandard care for current patients and we’re also being forced to not be able to train our future physicians and our future OB/GYNs to provide this care which will certainly, in my opinion, harm future patients. Thank you.

[00:32:26]

RICK WEISS: Thanks Dr. Steinauer. Again, very interesting perspective on the ripple effects of some of these rulings that I think a lot of people may not think about, that travel not just through the patient population but through the medical education department and then back to patients again. Before we get into our Q & A, I want to remind our reporters online that to submit a question, please just go down to the Q & A tab there and insert your name and news organization and your question. But I like to start these briefings in general first of all with a question from SciLine and that question is really aimed at helping reporters hear from experts on how they are doing as they cover the particular beat that we’re talking about. So I want to ask each of our presenters today if they could address the question of what do you see as you serve not only in your professional roles, but as readers and viewers of the news? What do you see that either reporters are getting right and doing well as they cover this beat or do you have any suggestions about ways in which they might handle this beat better than they are right now? And I’ll start with you Dr. Norris.

[00:33:39]

ALISON NORRIS: Thanks very much. One thing that we’ve seen is that with the focus on abortion there has been a lot more reporting on abortion and a lot more, of course, conversations in many, many spaces about abortion. And I think, you know, stigma itself is one of the barriers to obtaining abortion, to abortion care, it makes it harder to access. And so good reporting that tells the stories of people who are using abortion, in fact, brings forth normal stories of ordinary people who are very identifiable and the conversation itself serves to de-stigmatize. So the conversation that reporters are bringing forth into the media itself is quite important in terms of de-stigmatizing and educating people about the availability and the commonness of abortion. Abortion access gives people bodily autonomy, which is a really good thing. So often a lot of our reporting and the way we talk about abortion is like very, I would say, like it’s very sort of sad, like we’re talking about things that are challenges reading outline burdens or barriers, and there’s another side to abortion care, which is that it allows people to make decisions about their body and their future. Which is a really positive thing. So I just, I would encourage reporting on abortion to look beyond the numbers, look beyond the kind of hype and the politics and be willing to tell the stories about people, both the positive and the negative aspects of those stories. We often talk about if someone gets an abortion, it’s a great victory, they’ve traveled thousands of miles. Often it comes at huge cost to that person and so telling the richness of those stories, I think, is a really critical piece of this work that the reporting can do. Thanks.

[00:35:28]

RICK WEISS: Yeah, that’s very interesting, you know, we talk a lot at SciLine about not just covering the policy and the politics, but covering the science and the research as well. But a third leg of that stool, arguably is the anecdotal element that really sort of helps bring home the full truth of what’s going on. So thanks for that, Dr. White.

[00:35:49]

KARI WHITE: I want to echo a lot of what Dr. Norris said, and with respect to bringing some of these personal narratives into the reporting. I think that’s really powerful, both for trying to de-stigmatize abortion, but I think also presenting the complexities in which people are making their decisions. That there are a lot of reasons that people are coming to this decision to end their pregnancy, there are a lot of hurdles that they need to navigate to try to get to care, which really illustrate the many other policy shortcomings that we have in the United States that I think are really important to highlight and help communicate the ways in which abortion care is just part of the landscape and policy and service setting in which people are making decisions about their health.

[00:36:43]

RICK WEISS: Right, thank you. Dr. Steinauer.

[00:36:46]

JODY STEINAUER: I would agree with what both Dr. Norris and Dr. White said, and would just add similarly I think, well it’s because of my passion for medical education, but the stories that the learners are experiencing. I mean I’m hearing so much distress from learners, for example, senior residents who are seeing that their new interns who have just come in with this vision of being trained to be outstanding physician and having close positive ethical, you know, relationships with patients and supporting autonomy are absolutely so distressed and they’re so worried that these interns are going to learn care that is not standard of care. You know, these stories that you’ve heard about forcing people to delay miscarriage management, ectopic pregnancy management, and they’re really worried that they’re going to finish residency and not be able to provide good care. And there’s a lot of emotional and philosophical changes that these learners are experiencing. So, I think, I think also telling stories of the learners and the caretakers. And the experience of having to travel to a different state for training and I’m also hearing stories about how in a way, that is great, it de-stigmatizes abortion, these learners from Texas are going to California for training, and they cannot believe how it’s just part of normal healthcare. You know, and then they have to go back to where it’s restricted again and it’s causing a lot of challenges. So, I think telling the stories and not forgetting about the future generation.

[00:38:14]

RICK WEISS: That’s, that’s fascinating to hear. Thank you. OK, we’ll get into some questions here and I have one here from Helen Thompson at Science News. At this point do we have any data on the impact of Dobbs on travel distances and whether greater travel distances are preventing people from traveling to get abortions even more than before Dobbs?

[00:38:44]

ALISON NORRIS: We, I would love Dr. White to take a swing at this one, because I know that some of her groups work really centers on this, in terms of some specific data points to this question. The—it’s a very complex environment across the country and one of the things that has changed over the months since the Dobbs decision is that there’s more information available for people about where to get an abortion that’s available online, there’s more information about self-management of abortion, so people don’t travel, they manage their abortion at their own home by taking pills, and there’s also better networks of the kinds of practical support that is available to people who do need to travel; money to pay for gas or hotels. And so, or the abortion care itself. And so, in all of those sort of dynamic environments, we think that people both are traveling and are able to travel more successfully, and at the flip side, surely there are thousands and thousands of people for whom those practical supports are insufficient to overcome the barriers. And the travel is too far and they don’t travel.

[00:40:08]

RICK WEISS: Dr. White, do you want to add anything to that?

[00:40:12]

KARI WHITE: Sure, I think there have been some estimates that Dr. Caitlin Myers at Middlebury College has made that have demonstrated that for many people, a travel distance beyond 200 miles one way can effectively trap people into either continuing their pregnancy or self-managing their abortion if they have information about how to do so. We know from our research in Texas that there are many people who can travel beyond 200 miles, but certainly many people can’t and some of the things that make it difficult for people to travel that distance is that the many things that they need to do in order to make the trip, finding financial assistance from nonprofit abortion funds, scheduling an appointment, arranging travel, all of these are different phone calls, it’s really putting a lot of burden on the patient to try to figure out where to go, get these resources, in a very limited amount of time when they’re juggling many other things that are going on in their life; work, childcare, caring for someone else in their family. I think another thing that we’re also seeing here in Texas that is, that is unique to this particular state and some other states along the U.S.-Mexico border is that there are these interior border checkpoints that are within 100 miles north on the U.S. side of the border and that makes it very difficult to impossible for people who either themselves do not have legal authorization to be in the United States or whose travel companion does not have authorization that it makes it too risky or impossible for them to cross those interior border checkpoints and get care in another state.

[00:42:05]

RICK WEISS: That’s very interesting element, I mean we heard a lot from you folks about some of the inequities that get amplified by this problem, but that’s one I hadn’t thought about on the immigration side. Thank you. We have a question here from Kate Payne, with WLRN Public Media in Miami; from what I’ve read, there simply isn’t enough capacity in abortion rights states to accommodate medical residents from abortion restriction states, how significant is that bottle neck for learners who go without that training and what does it mean for the accreditation of those OB/GYN programs?

[00:42:48]

JODY STEINAUER: We do suspect that there will be a bottleneck. There are definitely, we’ve—we’re actively working along with the American College of OB/GYN and the Council on Resident Education OB/GYN to try to match programs in restricted states with non-restricted state programs. We do expect that we will have a hard time matching all of them, but we’re actively working on this. One thing to remember is that OB/GYN is just one sub-special—one sub—one specialty and family physicians also would like to travel to be trained, and then we have medical students who would like to spend time in settings where abortion care is provided. So, and then we have nurses, we have advanced practice clinicians, physicians assistants, midwives, nurse practitioners, who can provide in many states as well. So, there are so many healthcare professionals who need to be trained, educated about and trained in abortion care that we do—this is a big puzzle that we’re working on. We have found that even when those relationships exist, where a program has relationship with another host program, that of course some residents can’t travel, they have family responsibilities, and so it’s, you know, we’re not going to be able to train every single resident and so we’re also working on lots of strategies in the programs, developing better curricula, developing simulation for counseling and procedures, trying to improve the care we provide for people with pregnancy loss, which has a lot for overt transferable skills. So there’s a lot of strategies being employed and we’re all trying to work together on these.

[00:44:23]

RICK WEISS: Thank you. See here’s a couple of questions from Kari Beal from Fox Carolina News in Greenville, South Carolina. First, when Dr. Norris spoke, a graph showed that abortion rates in the Carolinas actually seemed to increase slightly after the overturn of Roe v. Wade. Can you explain why that might have been? Second, South Carolina has gone back and forth on approving stricter abortion bans, lawmakers passed a ban and then a judge halted the decision. What confusion and challenges can this cause in the medical field?

[00:45:01]

ALISON NORRIS: Thanks very much. It is needed the case that many states like the Carolinas, that have multiple restrictions on abortion, for example, waiting periods, sometimes very long waiting periods, gestational limits at 15 weeks or 18 weeks, the inability of people to use state health insurance to obtain an abortion, there’s sort of multiple different types of restrictions that make abortion harder to obtain, but are not bans outright on having an abortion. It’s a thing to navigate with quite a bit of complication, but there are clinics open and abortion is provided up until whatever that gestational limit is, and the vast majority of abortions happen before 15 weeks or 18 weeks of gestation. And so in a state like North Carolina or Florida, which has many different restrictions, but still has clinics that are open, and in the case of Florida, many clinics that are open a lot of abortion is being provided in those places and as states nearby ban abortion completely, patients will go to those states, because they’re close by, they don’t go because abortion is easy to get there, they go there because abortion is possible to get and it’s close at hand.

[00:46:24]

ALISON NORRIS:And needed, to your second question about this experience of churn, right, so it is not able—it is not easy to be crystal clear because day to day, the information changes in terms of what’s permitted, what’s been passed in legislature, when the judges then make a decision, when that judge’s decision will become—will become actualized in practice, and those uncertainties impact patients, because it’s very hard for patients to know what’s legal, it impacts the caregivers who are trying to stay current with the law as it is changing day by day, and it really impacts the abortion adjacent providers, as Dr. Steinauer said, it’s really anyone who has a pregnant patient is going to have the opportunity to consult with that person about what they should be thinking about for that pregnancy and we, all of us on this call have been involved in research with those adjacent abortion providing adjacent clinicians, and it’s very, very distressing for them to try to provide high quality, clear, correct care for patients in these very uncertain environments where the institutions where they work are giving them conflicting information as are the courts. So you are correct that those, that uncertainty creates a whole set of additional barriers beyond the ones that are required by, that are brought about by the laws.

[00:48:03]

RICK WEISS: A questions from Nancy Berrian, a freelance reporter based in Easton, Pa.: Did I hear correctly that some states have banned abortion altogether or did I misunderstand that some states just have tighter restrictions than others? There’s a second part of this question that I’ll save, but just to clarify that fact, are there any states that have just flat out banned abortion top to bottom?

[00:48:34]

KARI WHITE: There are states that have banned abortion in nearly all circumstances. Texas is one of those states that has very, very narrow exemptions for the circumstances under which abortion can be provided. Tennessee and Idaho are other ones where there are nearly zero exemptions for care, and in fact, if physicians do provide care for patients who are experiencing a medical emergency, they are then responsible for defending their actions in court to demonstrate that the care they provided was absolutely medically necessary. These are some of the most extreme abortion bans that we are seeing in the United States, in some of these states.

[00:49:20]

RICK WEISS: And related to that, there was mention of some exemptions for the mother’s health. How is that defined and does it include mental health?

[00:49:32]

KARI WHITE: It really depends on the state. And oftentimes the interpretation of these exemptions will come down to a specific institution and the legal guidance that providers are being given at the place in which they work. There are, there is language about whether or not there is a substantial risk to someone’s health, or severe bodily impairment and how that is interpreted, what constitutes severe, what constitutes major, is open to interpretation and can be very difficult to operationalize in practice.

[00:50:19]

RICK WEISS: Well it seems tough for a doctor when you have to go with the court’s definition of a word.

[00:50:25]

JODY STEINAUER: Yeah, and can I add to that? When the second part I think of that reporter’s question was about physicians banding together and this isn’t exactly the question they asked, but because it wasn’t, it’s not so much geared toward policy on a state level, but in many of these states, we are seeing incredible work where physicians who are specialists in internal medicine, who are neurologists, cardiologists, also maternal fetal medicine specialists, who are the subspecialty in OB/GYN who take care of pregnant people with complicated medical conditions, who are working together very closely to try to make sure that people are getting the care they need in pregnancy who have complications, and it’s actually been remarkable. Like statewide groups meeting, and the Society of Maternal Fetal Medicine has been a leader in this work to try to make sure that people are getting the abortions that they need within the state laws, and so that’s one really positive thing that has come out of it. I’m seeing, we’re seeing much more collaboration and work across specialties to try to support patient care and prevent death.

[00:51:41]

RICK WEISS: Interesting that that’s part of the impact that’s coming out of this movement. So, very interesting to hear. Question here forum Rachel Mipro from Kansas Reflector: Here in Kansas we’ve seen the quote-unquote, “Born Alive Bill and Abortion Reversal Bill,” pass in recent months. On a national level, what’s the impact, if any, of these types of bills on abortion care? And one of you describe what’s going on there and whether that’s spreading.

[00:52:15]

ALISON NORRIS: I don’t have an insight about whether any one particular law in one state has a national impact, expect for the fact that we do see a phenomenon that state legislatures borrow laws that have been passed in one state and then they pass them in other states, and so in that way some of these bills that are kind of confusing and add to this abortion care churn and this uncertainty, can be used in other spaces that they hadn’t been used before. And I think a really key role that reporters have is in clarifying, talking to experts so that the words that you use to talk about the bills reflect the way that healthcare providers and public health people think that those bills will be impactful as opposed to the language that the legislators use, many of whom are not in public health or medicine and may have language that’s farther confusing the situation.

[00:53:26]

RICK WEISS: Great. Another sort of state specific question here that perhaps one of you has some insight into, as a reporter—this is garment freelancer Cecelia Nowell in New Mexico, reporter based in New Mexico; I was surprised by the relatively low increase in abortions provided here since Dobbs, compared with Illinois, Florida, and North Carolina. I’m curious whether there’s any data on the impact of the physician shortage on access to care in states like ours. Any advice there, or a place you might point Cecilia to?

[00:54:03]

KARI WHITE: I’ll take that and then Alison, maybe you can chime in afterwards. I think one of the reasons why New Mexico doesn’t show as large of an increase as we might have anticipated following the Dobbs decision is because New Mexico had already seen a considerable increase following implementation of Texas Senate Bill 8. We saw that hundreds and thousands of Texans were getting care in New Mexico after September 2021, when Senate Bill 8 went into effect. And so the increase that we see in New Mexico is not as pronounced as it might have otherwise been had that prior trend not been in place. I’ll also add that it has only been recently that some new providers have begun offering abortion in New Mexico and so it may be that those numbers increase over time but I’ll let Alison chime in about any additional information she’d like to provide.

[00:55:02]

ALISON NORRIS: That, you made the main point, which is that in those data that we have, we only have 2 months of pre-Dobbs data, so when we look at Texas, the decline in Texas, it already had built into it that 50 percent of patients who needed care in Texas weren’t getting it in our pre-Dobbs baseline. And likewise our New Mexico baseline includes all kinds of patients who were already had been surging into the state for a year and so the dynamism that’s seen in some states right after the decision, has basically already happened before the study started. And one thing that I’ll note is that some states have seen increases but they’re slower and steadier and it’s partly because it takes time for clinics to come into the state, set themselves up, and begin to have patients coming in. Others are clinics that are already there are building up capacity to take care of more patients. And it shouldn’t be, I don’t want to mislead that a state that has a small increase maybe had a small increase in effort to provide care. Because any time that—we have been told by clinicians that when taking care of patients from out of state, they tend to be coming later in gestation, they are sicker, and they are really distressed. So it takes a lot of work to provide excellent care to a more distressed patient. And so even if the numbers, you don’t see huge numbers changing, you may find that the clinics are really going above and beyond to give excellent care to those—to those patients, and that the patients from New Mexico are also part of that experience of a clinic itself experiencing a surge, either in numbers or in the complication of the patients.

[00:56:42]

RICK WEISS: Great. We are just about at the top of the hour, I want to squeeze in a quick question and a quick opportunity to give each of our panelists today, to give a take home message to the reporters on the line today. So please hold for that, but a quick question for Dr. Steinauer, in 30 seconds or less, what about cross borders? Are physicians in the U.S. collaborating with those in Canada say, which I noticed was blue on one of those maps, and are patients going to Canada? Is this an international effort or really something that’s U.S. centric?

[00:57:11]

JODY STEINAUER: I don’t know the answer to that question but I bet these guys do, about travel across state lines, I mean across borders.

[00:57:19]

ALISON NORRIS: I’m going to guess it’s not happening too much to the north because people can get abortion in states mostly in the north or they’re going to other states without having to cross.

[00:57:28]

RICK WEISS: OK, great. Last thing I’d like to do here is just ask each of you in 30 seconds or less, is there a take home you want to leave these reporters with? What’s the one core message if they’re going to walk away with one thing, what do you want them to know, who do you want them to see? And Dr. Norris, I’ll start with you.

[00:57:46]

ALISON NORRIS: Abortion is really very normal, it’s very important, those of us who are researchers and reporters have tons of resources to navigate complicated healthcare problems, and yet many of the people who need abortion don’t have all those resources, so I would urge you to continue to center those who are most impacted at a loss of abortion care.

[00:58:05]

RICK WEISS: Thank you. Dr. White.

[00:58:07]

KARI WHITE: I think really keeping an eye on the regional impacts that this change in policy at the federal level is having is key. As you can see from some of the information that Dr. Norris provided, the shifts in where people are able to get care are very concentrated in different regions and I think it’s really important to keep an eye out on that.

[00:58:31]

RICK WEISS: Dr. Steinauer.

[00:58:33]

JODY STEINAUER: I would just say that many educators and health professions and education are very concerned about the impacts of Dobbs on medical education and nursing education and we’re working hard to make sure to train the next generation so that the impacts of Dobbs does not reach into states where people are cared for by inadequately trained physicians, wherever they end up practicing.

[00:58:57]

RICK WEISS: Alright, with that I want to thank our panelists today, our experts who spoke today, and as well as all of you reporters who have been on the line to learn and share some of this information in the stories that you’ll be writing. For those of you attending, reporters, please make sure to follow us on Twitter @realsciline, and check us out at SciLine.org, and we look forward to seeing you at the next briefing. Please, as you logoff today, reporters, you’ll note a quick survey, it’s just three questions, it’s very helpful to us if you provide some answers to that and we’d really appreciate it if you’d take the 30 seconds it takes to do that. Thank you all, and we’ll see you at the next briefing.