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After completing her residency in New York City, OB-GYN Alex Woodcock came home to Utah in the summer of 2022 to start a complex family planning fellowship at the state’s flagship university. Just as she arrived, the U.S. Supreme Court overturned Roe v. Wade, the longstanding precedent that held that abortion access was constitutionally protected.
She immediately wondered: “How is this going to impact other people that are applying for fellowships, or even applying for jobs, from the class below me, and where are they going to go? Are people going to want to come to states that are restricted?”
So she set out to find those answers, reaching out to hundreds of OB-GYN residents across the country.
Of the more than 300 who responded, nearly 1-in-5 said they had altered their intended practice state following the Dobbs decision, and those who initially planned to practice in states that restricted abortion were eight times as likely to have decided to work somewhere else. Woodcock’s findings were published in the journal Obstetrics & Gynecology on Thursday.
Approximately half of residents who responded to an open-ended question about the impacts of the changing abortion landscape on their lives said they were unwilling to live in a state with restrictions, and a quarter of those applying to fellowship programs, like Woodcock’s, reported that they either ranked programs in restrictive states lower or didn’t consider them at all.
In Utah, where abortion remains legal up to 18 weeks, but a near-total ban sits in front of the state’s Supreme Court, Woodcock said that means the OB-GYN residency program at the University of Utah — the only one in the state — has had to work harder to recruit, and that women’s health in the state, overall, could be upended if the trigger law were to go into effect.
Under the 18-week ban, Utah is classified as “restrictive” by the Guttmacher Institute, whose classifications Woodcock used in analyzing survey responses.
A quarter of OB-GYN residents who were planning to practice in states labeled “restrictive” changed their minds, according to the paper. But Utah also has a trigger law held up in court, which would move it to the “most restrictive” category, under which nearly 40% of residents sought a new state to practice in.
“The fewer qualified OB-GYNs, and whatever specialty we have, we’re going to get greater wait times to see specialists, then in turn, perhaps greater morbidity and mortality for females,” Woodcock said. “So I think one is just going to follow the other.”
Harms to health
Although it sunk during the pandemic, Utah has seen maternal mortality rates well above the national average in recent years. In 2020, the mortality rate was 15.3 per 100,000 live births, according to the most recent data from the Utah Department of Health and Human Services. But in the two years prior, the rate was 25.6 and 23.3.
In addition to caring for parents and fetuses during pregnancy and through delivery, OB-GYNs fill a variety of roles in both hospitals and clinics, including treating health conditions related to menstruation and women’s reproductive organs, as well as offering guidance in creating birth control plans.
Training in providing abortions, and when to recommend one, has uses beyond offering care to people who are electively choosing to terminate a pregnancy. It requires trainees to respond to and help navigate a miscarriage, but that’s not all.
Woodcock also notes that it would be difficult for a fertility specialist to recommend someone try to get pregnant if there are concerns that something could end up going wrong, and the parent wouldn’t have access to an abortion. She also said if a pregnant person has cancer and needs treatment, there are questions as to whether bans would allow them to abort the fetus to seek help.
“If things were to change and the trigger ban would go into effect, then we would be at risk of becoming like an Idaho,” Woodcock said. “I seriously believe that we have amazing (maternal-fetal medicine specialists) and complex family planning doctors here, even just general OB-GYNs — I feel like many people may leave if we continue to restrict abortion access here.”
In Idaho, which has one of the strictest abortion bans in the country, OB-GYNs have left en masse, forcing some hospitals to shutter their labor and delivery wards and creating maternal care deserts.
Pleading with policymakers
At an August meeting of the Utah Legislature’s Health and Human Services Interim Committee, Woodcock’s mentor, David Turok, told lawmakers during a presentation on reproductive health access that one of the most effective ways of improving women’s health outcomes is to grow the maternal care workforce. And abortion restrictions keep states from doing that, he said, referencing Woodcock’s research.
“I’ve never seen somebody die from an ectopic pregnancy until this year,” Turok said. “We’ve seen people who have had dramatic and unfortunate outcomes earlier in pregnancy due to lack of access locally and in surrounding states. So this is a major connector and driver for our ability to recruit and retain workforce for the future, and we’ve already seen it in applications locally and nationally for medical training, especially for OB-GYNs.”
Rep. Ken Ivory, R-West Jordan, who co-chairs the committee, asked, “With respect to your last comments, I’m just curious, are you advocating that we ignore or violate state law?”
“Not at all,” Turok said, continuing, “By respecting the full range of reproductive options for people, we can move forward in a way that helps people plan their pregnancies. And that ... has helped me when in one moment I’m providing care for somebody who’s continuing a pregnancy that puts their life literally at risk, and in the same day, taking care of somebody who’s ending a pregnancy or has ended a pregnancy because autonomy was a deciding factor for that.”
“I’m actually surprised you’d like to step into that,” said physician and state Sen. Mike Kennedy, R-Alpine, the other co-chair. “We’d like to continue to engage, but this is not the setting or circumstances where I’m interested in having you engage on that topic.”
Like Turok, some of the OB-GYN residents who responded to Woodcock’s survey said they are avoiding practicing in states with restrictions because of how those laws might complicate their work, and force them to make decisions that put them at risk of criminal prosecution. Many worried about how abortion bans would endanger their own, or their partner’s, reproductive health.
As she continues her research, Woodcock has begun interviewing some of the survey respondents, asking them questions about what’s driving their career decisions.
“One of the most interesting questions that I’ve asked people so far is: If you had the ear of a policymaker, what would you tell them?” Woodcock said. “The majority of these people are saying, I would love these policymakers to work with me for a day, to follow me around in my clinic, to listen to these patients and see what it is that I’m working with and dealing with.”
One of Utah’s policymakers has done that — and more. When she isn’t on Capitol Hill, Rep. Rosemary Lesser, D-Ogden, works as an OB-GYN, and is a fellow with the American Congress of Obstetricians and Gynecologists. She also was present at Turok’s presentation to the interim committee.
Lesser told The Salt Lake Tribune that she shares Turok’s concern that new OB-GYN residents will stop coming to Utah if the trigger ban is reinstated, and that young medical students will stop choosing to enter the OB-GYN field.
“I really do fear for Utah’s ability to attract doctors, when, in this competitive world of medicine, they can go [practice at a hospital] where legislative bodies respect their judgment and the judgment of their patients,” Lesser said.
She continued, “There will be delay in getting care, because if you have limited numbers of providers, and the same number of patients, which we know from our Utah population going up, that will be, I think, a real catastrophe.”
‘Potential losses ahead’
If Utah goes down the road of further restricting abortion, and the number of OB-GYNs in the state goes down, Lesser said it won’t be a quick fix. It can take over a decade for OB-GYNs to complete their schooling.
Other state lawmakers are not as sympathetic to OB-GYNs on the front lines of navigating abortion restrictions. Last September, a group of Republicans from the Utah House of Representatives printed letters on the body’s letterhead that they sent to abortion providers, threatening prosecution if they violated the enjoined trigger law.
They later walked back the threat, saying it was merely their opinion.
Neither Republicans Sen. Dan McCay nor Rep. Karianne Lisonbee, the lawmakers who sponsored the trigger law and another bill further restricting abortion access that passed this year, responded to requests for comment.
Lisonbee worked with OB-GYNs in the state to clarify some of the definitions and requirements around abortion during this year’s legislative session, but the legislation — which is now also enjoined in court — ultimately looked to bypass an injunction on the trigger ban by banning abortion clinics and moving the procedure to hospitals, where abortions are only performed in rare circumstances.
“When you’re thinking about providers who are starting their first job, you’re wanting to be in a place where you have support and are able to do the maximum of the capabilities that you’re trained for, without threat of legal return or compromising your own reproductive health,” Woodcock said.
As many OB-GYN residents are preparing to take the first steps in their careers, Woodcock is thinking about her next one. Like many of those surveyed, the doctor who grew up in Park City, and whose family lives here, is looking to work in a place without abortion restrictions — one outside of Utah.
Turok told The Tribune that Woodcock exemplifies the many “extraordinarily capable people who have plenty of reasons to stay here go elsewhere. It just is a clear representation of the potential losses ahead.”