Healthcare Inequities Post-Roe: Clinician Perspectives

Many states with abortion bans are also states with higher proportions of people of color, increasing the uneven impacts of the Dobbs decision, which overturned Roe v. Wade.

The Doctors Company recently invited three prominent ob/gyns to present frontline clinician perspectives on reproductive healthcare post-Roe. Their expert discussion illuminates how restrictions on access to reproductive care disproportionately affect people of color, as well as low-income patients and others already negatively impacted by the social determinants of health.

Treatment practices that have long been the standard of care are now criminalized in some states, and our physician experts expressed special concern regarding the uneven distribution of the risks and burdens of being denied care, of potential criminalization, and of the damage already done to the physician-patient relationship.

Location Matters

Prior to the Dobbs decision, patients’ access to reproductive healthcare was already determined partly by their location, given that some patients reside in maternity care deserts and must drive hours to access ob/gyn care at all. Also, some patients live in states with abortion restrictions that predate Dobbs. Still, the Dobbs decision has amplified the contrasts between states with higher and lower rates of access to reproductive healthcare.

The sheer scale of U.S. geography becomes a formidable factor in access to care with post-Roe widespread bans. “The distances that patients are having to travel now have just become enormous,” says Daniel Grossman, MD, Professor at the University of California, San Francisco, and Director of Advancing New Standards in Reproductive Health (ANSIRH). “A patient who is in Houston who needs to access a first-trimester abortion, now is looking at the nearest place for in-person care to be in Wichita, Kansas, which is about 700 miles away, about a nine-and-a-half-hour drive each way. If that clinic is too backed up, we're talking about other options that are potentially over 800 miles away.”

In many states today, patients face long drives, time away from work and family, and potentially burdensome expenses, only to find that clinics are too booked to see them or perhaps only to be turned away.

The Physician-Patient Relationship Is Endangered

Even when restrictions to reproductive healthcare don’t bar a patient from accessing an appointment, they can still compromise the physician-patient relationship in ways that create patient safety risks, says Ghazaleh Moayedi, DO, MPH, of Pegasus Health Justice Center in Texas. Patients who are pregnant or recently were pregnant could need care from a clinician in any specialty, and it is unhelpful at best, but dangerous at worst, for patients to feel they must conceal critical information about their health. In this volatile legal environment, she says, “Patients are afraid to tell their physicians or clinicians the truth about accessing self-managed abortion,” or even “having a miscarriage…it will make it more challenging for us to provide healthcare.”

These challenges related to patient nondisclosure are not limited to states with abortion bans. Sheila Dejbakhsh, MD, MPH, of Orange Coast Women’s Medical Group, is quick to point out that even in states with ongoing access to abortion, patients’ fear of criminalization corrodes the clinician-patient relationship. “Even in this state,” says Dr. Dejbakhsh, describing conversations with patients in California, “this new ruling has created such fear.”

Online Access Is Uneven

Patients who wish to self-manage their abortion have more options today than during the pre-Roe era, but these options feature disparities in online access, internet literacy, health literacy, and access to emergency care.

For instance, through AidAccess or another organization, patients may be able to access “the very same medications that we use for a facility-based medication abortion, either mifepristone together with misoprostal, or misoprostal used alone,” Dr. Grossman says. Fortunately, these patients’ mostly experience safe outcomes: “I don't have many medical concerns about a patient self-managing their abortion with these medications,” Dr. Grossman says, based on the published research, “provided they have good information about how to screen themselves for eligibility, they know what to look out for in case of a complication, and they have a place to access emergency care.”

The criteria Dr. Grossman outlines are a barrier to this care for patients who do not all have sufficient access to quality information or emergency care.

Rates of Criminalization Are Uneven by Race and Income Level

All three physicians expressed serious concerns that their patients could be criminalized, whether for seeking an abortion from a medical professional, for a self-managed abortion, or even for seeking treatment during a miscarriage—knowing that patients who are people of color, low income, from an immigrant community, or otherwise already marginalized face the sharpest risks of becoming targets of the criminal justice system, and of poor outcomes if prosecuted. Criminalization, even or especially for suspected “abortions” that are actually miscarriages, is likeliest to fall most heavily on patients who are people of color.

More Infrastructure for Care Is Needed

Given the number of states with partial or complete abortion bans, “We need a huge expansion in our infrastructure,” Dr. Moayedi says. She emphasizes, however, that the infrastructure we need is already in place. “There isn't a reason,” she says, “that every hospital in California shouldn't be providing abortion care right now.”

Dr. Dejbakhsh, however, identified cultural reasons why more hospitals in California and other states with abortion access aren’t already preparing more procedure suites. As an abortion provider, she says, “I'm still kind of at odds against overall hospital culture.” She identified a need for education for her fellow medical professionals being key for “an effective cultural shift”: “They don't see it as a human right,” she says. “Things are moving in the right direction,” Dr. Dejbakhsh acknowledges. “But it's harder than it seems.”

Additional resource: Solutions for Reducing Racial and Ethnic Disparities in Healthcare (on-demand webinar)

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.