The Dobbs Decision: The Unforeseen Consequences of Restrictive Abortion Legislation

On June 24, 2022, the Supreme Court issued the Dobbs decision, which no longer grants; abortion to be a constitutionally protected right for patients. This decision caused an overturn of; Roe v. Wade, which has had unprecedented consequences for patients and medical providers.; The literature reviewed for this policy analysis suggests that the policy change did not account; for many aspects of healthcare. There have been several articles published by providers; regarding the challenges of navigating care for their patients in restrictive abortion states.; Personal stories of patients have emerged regarding how their experiences with the healthcare; system have changed when attempting to access reproductive care services. The areas of policy; analyzed include an overall background of abortion laws, state and federal concerns, legal; concerns of providers, patient effects, and retention and recruitment of obstetric and gynecologic; specialties. Studies analyzed show that the Dobbs decision and subsequent restrictive state; abortion legislation has increased pregnancy-related mortality and illness due to delayed care for; women, including increased travel times for abortion and decreased access to healthcare. There; have been several adverse outcomes to healthcare; these include a potential decrease in access to; contraceptives, under-identification of sexual abuse victims, increase in ethnic disparities,; socioeconomic concerns, and legal implications for infertility treatments in certain states. Future; implications include increased involvement of healthcare providers in policy development,; comprehensive sexuality education for restrictive states, protected reproductive care for women; in their local states, and clear guidelines for healthcare providers assisting women with; life-threatening disorders while pregnant.

THE DOBBS DECISION 1 The Dobbs Decision: The Unforeseen Consequences of Restrictive Abortion Legislation Aleczander Rodriquez, Carter Mitchell, Ivy Welch, and Kaylee Bruno Westminster University MSN 610: Master’s Project Dr. Julie Balk, DNP, APRN, FNP-BC December 3, 2023 Author Note In this paper, the following terms are used interchangeably regarding access to abortion: Dobbs decision, The Dobbs v. Jackson Women’s Health Organization, Dobbs v. Jackson, and the overturn of Roe v. Wade. The term pregnant women will be used to refer to all persons who become pregnant. We acknowledge that this does not encompass variations in gender identity. The data on this topic, specifically the legislation, is frequently changing. The information in this paper is current as of the manuscript completion date unless specified otherwise. THE DOBBS DECISION 2 Abstract On June 24, 2022, the Supreme Court issued the Dobbs decision, which no longer grants abortion to be a constitutionally protected right for patients. This decision caused an overturn of Roe v. Wade, which has had unprecedented consequences for patients and medical providers. The literature reviewed for this policy analysis suggests that the policy change did not account for many aspects of healthcare. There have been several articles published by providers regarding the challenges of navigating care for their patients in restrictive abortion states. Personal stories of patients have emerged regarding how their experiences with the healthcare system have changed when attempting to access reproductive care services. The areas of policy analyzed include an overall background of abortion laws, state and federal concerns, legal concerns of providers, patient effects, and retention and recruitment of obstetric and gynecologic specialties. Studies analyzed show that the Dobbs decision and subsequent restrictive state abortion legislation has increased pregnancy-related mortality and illness due to delayed care for women, including increased travel times for abortion and decreased access to healthcare. There have been several adverse outcomes to healthcare; these include a potential decrease in access to contraceptives, under-identification of sexual abuse victims, increase in ethnic disparities, socioeconomic concerns, and legal implications for infertility treatments in certain states. Future implications include increased involvement of healthcare providers in policy development, comprehensive sexuality education for restrictive states, protected reproductive care for women in their local states, and clear guidelines for healthcare providers assisting women with life-threatening disorders while pregnant. THE DOBBS DECISION 3 Table of Contents INTRODUCTION ……………………………………………………………………………..…4 BACKGROUND AND HISTORY ……………………………….……………………………....5 ACCESS TO ABORTION AND CURRENT LEGISLATION …………………...…………...…6 Figure 1 …………………………………………………………..…………...…..9 REVIEW OF LITERATURE ……………………………………………………………………13 Provider impacts...…………………………………………………..………...…13 Figure 2 …………………………………………………………..…………...…17 Figure 3 …………………………………………………………..…………...…18 Patient impacts ..……………………………………………………..………..…21 Figure 4 ……………………………………………………………..………...…26 Figure 5 ……………………………………………………………………...…..30 Figure 6 ………………………………………………………………..……...…32 Figure 7 ………………………………………………………………..……...…41 FUTURE IMPLICATIONS ………………...………………………………………………...…36 CONCLUSION .………………………………..………………………………………..………43 REFERENCES ……………………………………………………………………………….…45 THE DOBBS DECISION 4 The Dobbs Decision: The Unforeseen Consequences of Restrictive Abortion Legislation Throughout history, specifically the past 100 years, women’s reproductive health and rights have been at the center of many discussions, political and otherwise. Reproductive health involves topics such as access to reproductive healthcare, abortion, contraception, sexuality education, amongst others. The ability for a woman to decide what happens with her body and her ability to procreate is often controversial for several reasons: 1) the entire event occurs within the body of a woman, 2) all United States citizens have the right to choose what happens to their body, and 3) the fetus is unable to express their desires. Abortion is a highly politicized and controversial topic of discussion in the United States. From political positioning to religious views and medical decision-making, abortion means different things to different groups and has a different impact on everyone. With the overturning of Roe v. Wade (1973) in June 2022, the Supreme Court of the United States concluded that “The Constitution does not confer a right to abortion…and the authority to regulate abortion is returned to the people and their elected representatives” (Dobbs v Jackson, 2022). Abortion is a complex issue that has far reaching implications and cannot be limited to the stereotype of a young female wanting to terminate a pregnancy. This issue extends deeper into other facets of a woman’s, and her family’s, life (ie. finances, overall health outcomes including mortality, abuse, etc.). These issues do not seem to have been extensively reviewed by lawmakers, with the help of medical providers’ clinical expertise, prior to their implementation. This policy analysis aims to bring to light the serious consequences of restrictive abortion legislation resulting from the Dobbs decision, and the detrimental impact this ruling will have on all individuals, both now and in the future. A focus on the consequences of restrictive abortion legislation on patients and THE DOBBS DECISION 5 providers related to safety, legality, the long-term impact, and future implications will be reviewed here. History of Roe v. Wade and the Dobbs Decision In 1969, Norma McCorvey, known as Jane Roe to protect her privacy, became pregnant and desired to receive an abortion. Living in Texas at the time, abortion was illegal, except when utilized to save the life of the mother. In March of 1970 Roe’s lawyer filed a lawsuit against Henry Wade, the district attorney for her area. This case was then heard by a District Court in Texas, which ruled that the law was unconstitutional and violated a woman’s Ninth and Fourteenth Amendment rights. On December 13, 1971, an appeal was filed to the Supreme Court over the ruling. The purpose of this appeal was to “[challenge] the constitutionality of the Texas criminal abortion laws, which proscribe procuring or attempting an abortion except on medical advice for the purpose of saving the mother's life” (United States Supreme Court, 1973). At that time, Texas’ code defined abortion as “the life of the fetus or embryo [that] shall be destroyed in the woman's womb or that a premature birth thereof be caused” (1973). Ultimately, “the court declared the abortion statutes void as vague and overbroadly infringing those plaintiffs' Ninth and Fourteenth Amendment rights” (1973). Those rights being, 9th Amendment: “[t]he enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people” (United States Constitution, 1789); and the 14th Amendment: “[a]ll persons born or naturalized in the United States and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside. No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws” (1789). THE DOBBS DECISION 6 The aforementioned ruling stood as the legal stance of the United States on abortion until 2021. In December of 2021, Mississippi’s Gestational Age Act, stated that “[e]xcept in a medical emergency or in the case of a severe fetal abnormality, a person shall not intentionally or knowingly perform . . . or induce an abortion of an unborn human being if the probable gestational age of the unborn human being has been determined to be greater than fifteen (15) weeks (United States Supreme Court, 2022). Jackson Women’s Health Organization, “challenged the Act in Federal District Court, alleging that it violated this Court’s precedents establishing a constitutional right to abortion, in particular Roe v. Wade, 410 U. S. 113” (2022). Later, the “[c]ourt review[ed] the standard that the Court’s cases have used to determine whether the Fourteenth Amendment’s reference to “liberty” protects a particular right… [and concluded that] [t]he Constitution makes no express reference to a right to obtain an abortion” (2022). The Supreme Court then ruled, stating that “The Constitution does not confer a right to abortion; … and the authority to regulate abortion is returned to the people and their elected representatives'' (2022). Access to Abortion and Current Legislation Before the Dobbs decision, abortion was more broadly available and considered a constitutionally protected right. With the Dobbs ruling, each state or the federal legislature determines its abortion policy. In anticipation of the overturning of Roe v. Wade, nine states had already passed laws restricting abortion that would come into effect if Roe was overturned, called trigger laws. Trigger laws are used by states to prepare for changes in federal law preemptively. If the Supreme Court ever overturned Roe v. Wade, bans would go into effect immediately if a state had a trigger law in place regarding restricting abortion. Accordingly, immediately after this decision, abortion became illegal in nine states with trigger laws or bans; THE DOBBS DECISION 7 these states were Alabama, Arkansas, Kentucky, Louisiana, Missouri, Oklahoma, South Dakota, Texas, and Utah (Baden & Driver, 2023). Utah’s trigger ban was immediately challenged and blocked, allowing abortions for its residents until the fetus reaches 18 weeks (Welch, 2023). Wyoming also attempted to enact a trigger ban, which would make abortion, other than in incidents of rape or incest, punishable with up to 14 years in prison; this ban was also challenged and blocked, preserving abortion access for Wyoming’s residents (Gruver, 2022). Since the Dobbs decision, the abortion access landscape changed dramatically across the United States. Each state decides the legality of, and conditions for, abortion. Currently, there are 14 states, known as total-ban states, where abortion is unavailable or banned, with some limited exceptions (Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, and West Virginia). Additionally, eight other states, Arizona, Florida, Georgia, Nebraska, North Dakota, North Carolina, South Carolina, and Utah have enacted policies further restricting abortion access and limiting care. For the purpose of this paper, both states with complete bans, or limiting restrictions, will be referred to as “restricted states.” With such significant changes occurring across the country, states have many differences in their abortion laws. While several states have enacted laws that make abortion more restrictive and punitive, others have prompted laws to protect abortion access, and some have extended protections for those who must travel to their states for abortions. Some exceptions to receiving an abortion in the 22 restricted states include preserving a mother’s life, if the pregnancy severely impacts health, cases of rape or incest, or if the child has a fatal fetal anomaly. However, not all these 22 states have the same exceptions, and in the ones THE DOBBS DECISION 8 that do, proving an exception, finding an abortion provider, and navigating the legality can be difficult and pose challenges for all parties. When it comes to preserving the mother’s life, every state has an exception allowing an abortion to save a mother’s life, if necessary. However, there is no uniformity in the states as to how close to death or how much danger a mother must be in before the exception applies and an abortion can be performed; or if the healthcare provider treating the patient makes the ultimate decision or another party (Felix et al., 2023). In an interview with NBC News, a physician practicing in Texas explained that she has turned away patients with life-threatening conditions, such as kidney failure, and referred them out of Texas for fear of prosecution. Further, to avoid prosecution, her attorney has advised her not to perform any abortions unless a patient is actively dying in front of her (Bendix, 2022). While health-based exceptions exist for patients whose health will be seriously impacted by carrying on with pregnancy, definitions of what constitutes a health-based exception vary from state to state and are often unclear and vague. Most exceptions mention the incidence of permanent organ damage, long-term health effects, a life-threatening condition, or irreversible impairment; however, there is a similar theme to the life endangerment and abortion exceptions, where the language is vague and non-specific (Felix et al., 2023). A clear list of diagnoses and circumstances is not provided within the laws, language is ambiguous, medical professionals caring for these patients cannot make the determination, and the legality of each situation is in question, putting the patient, medical provider, and institution at risk of prosecution. Felix et al. (2023) assert, “the difficulties presented by the simultaneous vagueness and narrowness of the THE DOBBS DECISION 9 exceptions are exacerbated by the lack of deference given to clinicians’ medical judgment under these bans.”See Figure 1 for an example of the verbiage in these health-based exceptions. Figure 1 Language in health exceptions to abortion bans Note. From “A Review of Exceptions in State Abortions Bans: Implications for the Provision of Abortion Services,” by M. Felix et al., 2023 KFF. (https://www.kff.org/womens-health-policy/issue-brief/a-review-of-exceptions-in-state-abortions-bansimplications-for-the-provision-of-abortion-services/) A further concern with health exceptions for abortion is the notable absence of mental health as a consideration. The only restricted state with an expressed mental health exception is Alabama. To date, no other state has included mental health disorders that may be dangerous to a mother or unborn child, such as suicidal ideation, major depressive disorder, or any other significant mental health disorder, as a specific exception. The lack of mental health acknowledgement is especially concerning considering that when the Centers for Disease Control and Prevention (CDC) evaluated nearly 1,000 pregnancy-related deaths across 36 states, the leading underlying cause of death was mental health-related, accounting for approximately 23% of the 1000 deaths; these included deaths of suicide, overdose or poisoning related to THE DOBBS DECISION 10 substance use disorder, and other deaths determined linked to a mental health condition (Trost et al., 2022). According to the Guttmacher Institute, only seven of the 22 restricted or banned states include an exception for fatal fetal anomalies: Utah, Iowa, Indiana, W. Virginia, Florida, Alabama, and Georgia (State Bans on Abortion Throughout Pregnancy, 2023). Another abortion exception in some restricted states pertains to fetal life and health. However, it is usually limited to fetal disorders leading to death in the womb or death shortly after birth. Once again, what conditions qualify as fatal is unclear and poorly defined in states with these exceptions. The lack of certainty for this exception can expose both providers and patients to legal risks if they carry out an abortion believing a fetus is a risk. Additionally, in states where the medical provider is not the deciding factor as to what life-threatening is, good-faith medical analysis and the performing of an abortion for fetal health reasons may be challenged and result in prosecution, punishment, loss of licensure, and possibly imprisonment if they perform an abortion. The last category of abortion exception concerns pregnancies resulting from sexual assault, rape, or incest. These exceptions generally require some reporting by the medical provider to law enforcement. However, according to Felix et al. (2023), “state abortion bans do not make clear exactly what information needs to be given to a provider to make it clear that the abortion would be legal in that state.” Further confusing the situation, some states limit these exceptions by only allowing an abortion allowed by incest or rape if the abortion occurs before a certain gestational age, ranging from 8 weeks to 14 weeks. Most restricted states within the U.S. enforce at least one of the exceptions discussed; others have none and outright ban abortion for any reason other than to save the mother’s life. THE DOBBS DECISION 11 For example, patients living in South Dakota, Arkansas, and Oklahoma cannot get an abortion, even if it relates to the incidence of rape, incest, fatal fetal anomaly, or if it puts the mother’s health at extreme risk (Felix et al., 2023). To add to the legal situation’s complexity, certain states have multiple bans with contradictory exceptions. In Mississippi, there are different bans in place. One ban only provides exceptions in cases to save the mother’s life or in cases of rape; the other ban has exceptions limited to procedures done within 15 weeks of the mother’s last menstrual period (LMP) and only include exceptions for fatal-fetal anomaly, severe risk to a mother’s health, and to save a mother’s life, but does not include exceptions for rape (Felix et al., 2023). Mississippi patients with any circumstance, aside from saving the mother’s life, that could warrant an abortion would violate one of these bans if carried out. Other states have enacted laws that make abortion services more restrictive and punitive. Furthermore, some states have passed laws and restrictions that extend to those who may assist a person in receiving an abortion in any way. Texas has enacted its SB-8 law, allowing the public to sue an abortion provider or anyone who assisted a patient in accessing abortion services privately (Abortion Laws by State, n.d.). Other states, such as Idaho and Oklahoma, have emulated this law in their states, which have been coined “SB-8 copycat laws.” Not all the legislation passed is negative, 19 states have enacted “shield laws” protecting patients who must travel for an abortion and the providers performing them (Steupert, 2023). These shield laws generally mandate that the state will not assist with extraditing abortion patients, will not assist with information or investigation, will provide care for out-of-state patients, and will provide license, legal, and malpractice protections for abortion providers. Five THE DOBBS DECISION 12 states–Colorado, Massachusetts, New York, Washington, and Vermont–include specific protections for telemedicine providers, even if they treat patients in restricted states (Grant, 2023). These shield laws do have limitations. These protections are limited to the states that enact them, meaning patients and providers are only offered protections while in a safe state. Warrants, restrictions, and charges may proceed outside the shield state. Cohen et al. (2023) assert that there is little to no protection for patients returning to a restricted state following an abortion in a shield state. Also, like exceptions discussed earlier, these shield laws can be vague and not specify who and what is specifically covered, putting a patient and medical provider’s interpretations at risk. Furthermore, each state individualized its exceptions, which can be challenged or reversed at any point, some of which are made without the advice of medical providers. Such occurrences puts patients and medical providers at risk. For the medical providers, this also raises a potential ethical and legal dilemma, where the medical provider must choose between providing emergency care with the risk of legal consequences from their state or delaying care and potentially negatively impacting a patient’s health or life, potentially facing civil suits from the patient or their family for medical negligence. Either situation can result in loss of licensure, fines, and criminal charges. Another form of restriction is a mandatory waiting period or counseling before receiving an abortion. Currently, 33 states require a pre-procedure counseling appointment before obtaining an abortion, 28 of those states require a mandatory waiting period following that appointment (between 24-72 hrs), and 16 states require that counseling to take place in person, THE DOBBS DECISION 13 requiring two in-person visits (Counseling and Waiting Periods for Abortion, 2023). Restrictions such as these significantly reduce access to and prevent patients from getting abortions. For example, North Carolina currently has a 12-week abortion ban, requires counseling, and a mandatory 72-hour waiting period to get an abortion. They recently changed their requirements, making the counseling an in-person compulsory visit. In the month following this change, the state had a 31% decrease in facility abortions (Baden et al., 2023). Two in-person visits are not a medical necessity, as most states allow a telephone or virtual appointment; it is an unnecessary requirement and obstacle, making it harder for patients to get an abortion and for providers to perform them (Baden et al., 2023). Specifically, requiring two in-person appointments will impact out-of-state patients, who must make travel arrangements, get time off work, secure childcare, and have the funds for a minimum of 72 hours of travel (Baden et al., 2023). Lastly, requiring two visits means that clinics will need to schedule twice as many staff and in-person visits for the same number of patients, which causes additional delays for patients trying to receive services before 12 weeks of gestational age, and increases strain on the staff caring for these patients (Baden et al., 2023). Provider Impacts The uncertainty of the potential financial risks, criminal liabilities, training requirements, and varying legal requirements after Dobbs negatively impacts healthcare providers. Through the literature review, topics emerged: retention and recruitment of providers, medical training, legal concerns, prescriptive authority, and infertility specialists. The provider impacts to OB-GYN specialties have been the focus since the overturn of Roe v. Wade, but it has affected all healthcare providers. For example, “Health care providers, especially in emergency department THE DOBBS DECISION 14 and primary care settings, will need to become familiar with the normal course of self-managed abortion with medications and its rare complications, as well as complications of unsafe methods” (Harris, 2022). Retention and Recruitment of Providers The number of healthcare providers working in women’s reproductive health had steadily decreased before the Dobbs decision. A study by Rayburn & Xierali (2021) analyzed subspecialty resident physicians pursuing fellowships in OB-GYN specialties after residency, which decreased by 21% from 2001 to 2022. Prior to the Dobbs vs. Jackson, an OB-GYN had many obstacles, including medical ethics, vigorous medical training, and legal implications involved in caring for a mother and a fetus simultaneously. Post-Dobbs, prospective professionals could also become more hesitant to enter a women’s healthcare specialty due to increased costs and potential criminal liability. A study by Hulsman et al. showed how many residents choose their medical specialty and weigh many factors when choosing residency (Hulsman et al., 2023). “Approximately half of respondents were less likely to pursue obstetrics and gynecology as a specialty after proposed abortion restrictions” (Hulsman et al., 2023). With the recent policy changes, numerous providers have decided to move to states without restrictive or banned abortions in fear of repercussions of advocating for their patients, counseling their patients, and legal accusations. Pre-abortion and post-abortion care are prominent aspects that need to be evaluated; not only are there physical concerns that need to be addressed, but also psychosocial concerns. Education before the abortion procedure should explain risks vs benefits, which can help a woman with her decision-making. Aftercare of the abortion procedure can be time spent evaluating risks such as bleeding and checking in with the woman’s mental health needs. Due to THE DOBBS DECISION 15 the policy change and decreased access to local providers, much of the overall care for women has been detrimentally impacted. By removing abortion care from the hands of local OB-GYN, many of these patients are not getting the pre and post abortion care necessary. The evidence has begun to show that medical school applications have reduced in states with restrictive abortion care for patients. Recruiting physicians into the OB-GYN specialty is expected to worsen in restrictive abortion states. “Abortion bans could affect the recruitment process at multiple points during a person's journey through the higher education system, beginning as early as the college application process” (Thomas et al., 2023). According to Thomas et al. (2023), for the first time, college students are making their application decisions with guidance regarding where they can access reproductive care in their state. Recruitment has been affected due to uncertainty of family planning during rigorous medical school. "Medical students with no option but to carry a pregnancy to term, may have to take a leave of absence, require childcare during clerkships, or forgo completing their medical degree to raise the child. This will contribute to the current physician shortage in the U.S., further limiting healthcare access" (Traub et al., 2022). Retention of physicians has been affected because of the personal impact on physicians' access to reproductive care. “Unintended parenthood would amplify these inequities and could exacerbate work-life balance struggles, increase mental health challenges, slow career advancement, and potentially cause female physicians to abandon a medical career altogether” (Thomas et al., 2023). Medical Training Due to the Dobbs decision, providers cannot meet all patients’ needs in restrictive and banned states. These needs include counseling patients about abortion, contraceptives, THE DOBBS DECISION 16 miscarriage, infertility treatment, and preconception education. Separating abortion care from women’s healthcare has multifactorial challenges associated. OB-GYNs have routinely been expected to train in abortion care and feel comfortable performing abortion services. Prior to the overturn of Roe v. Wade, this was a typical section of medical training that included care of the women’s reproductive needs and being taught how to perform medication abortions and procedural abortions. These procedures are utilized for a broad range of medical diagnoses, including heavy menstrual periods, retained placenta after routine birth, and infection. “Because the procedural steps are the same for suction aspiration or dilation and curettage no matter the indication, ob-gyns already have the professional skills and expertise to provide procedural abortion in their medical practices” (Fay et al., 2022). A study by Vinekar et al. (2022) showed that upwards of one-half of U.S. obstetrics and gynecology residents will not get training on fundamental aspects of reproductive care due to the overturn of Roe v. Wade. Due to the decreased training opportunities, providers will not be ready to perform an abortion when it is needed. A study done by Vinekar et al. (2022), highlighted resident training in anticipation of the overturn of Roe v. Wade. This study represented 286 U.S. obstetrics and gynecology residency programs. Of these, 128 (44.8%) are in states certain or likely to ban abortion if Roe v Wade is overturned, as shown in Figure 2. More specifically, 111 programs (38.8%) are in states certain to ban abortion and 17 (5.9%) are in states likely to ban abortion (Vinekar et al., 2022). THE DOBBS DECISION 17 Figure 2 Obstetrics and Gynecology Residency Programs in the United States by Projected Legal Status of Abortion if Roe v Wade is Overturned. Note. Obstetrics and gynecology residency programs in the United States by projected legal status of abortion if Roe v. Wade is overturned. Total U.S. obstetrics and gynecology programs in 2022 (N=286); obstetrics and gynecology residency programs located in states certain or likely to outlaw abortion if Roe v Wade is overturned (n=128; 44.8%). (Vinekar et al., 2022) “There are 6,007 residents in accredited U.S. obstetrics and gynecology programs, and 2,638 (43.9%) train at programs in states that are certain or likely to ban abortion if Roe v. Wade is overturned” (Vinekar et al., 2022). One strategy mentioned in the study Vinekar et al. (2022) in addressing this gap in learning is the development of travel rotations for residents to obtain abortion training in states with protected abortion access. A barrier to this proposed strategy is that it will not be possible for about 44% of all U.S. obstetrics and gynecology residents due to residents not getting time off work for travel. THE DOBBS DECISION 18 Legal Concerns Prior to the overturn of Roe v. Wade, OB-GYN specialists faced many hurdles compared to other healthcare specialties. “Before they turn 55, over half of OB-GYNs have already been sued, and nearly two out of three OB-GYNs face legal action at some point, the highest rate of all specialties” (Roncoroni et al., 2023, p. 3). The provider takes on great responsibility with high-risk pregnancies and is caring for two patients consecutively, the mother and the fetus. With the increased liability of two lives comes additional expenses for the OB-GYN specialist, such as high malpractice insurance premiums up to four times the cost of the average physician, as shown in Figure 3. Figure 3 Malpractice Rate Note. This graph shows the cost of medical malpractice insurance costs comparing physician specialties. From Utah Medical Malpractice Insurance by Gallagher Healthcare, 2023. (https://www.gallaghermalpractice.com/state-resources/utah-medical-malpractice-insurance/https://www.gallaghermalpractice.co m/state-resources/utah-medical-nmalpractice-insurance/2). Copyright 2023 by Gallagher Healthcare. THE DOBBS DECISION 19 For example, Utah is a restrictive abortion state. The increased cost to practice has set a barrier to recruitment into the OB-GYN specialty. An article published by Roncoroni et al. (2023) mentioned that many resident physicians may not choose OB-GYN specialization, or OB-GYNs might leave their practice due to the specialty’s high likelihood of being sued (Roncoroni et al., 2023, p. 3). Prescriptive Authority The overturn of Roe v. Wade had a trickling effect on prescriptive authority of medications including abortion medications and non-abortion medications for women. “Because mifepristone and misoprostol are safe, the biggest risks to patients may be legal ones: threat of reporting, arrest, and detention” (Harris, 2022). Any healthcare provider prescribing medications with teratogenic side effects has had to reevaluate their decisions on writing prescriptions for women. The Dobbs Decision had effects on any healthcare provider prescribing medications since methotrexate (MTX) and other medications are used for several conditions. Due to the concern of prescribing to childbearing women, males are being prescribed more, and this has created discrimination for women seeking treatment for numerous conditions unrelated to reproductive care, including but not limited to acne, rheumatoid arthritis, lupus, psoriatic arthritis, irritable bowel disease, and musculoskeletal diseases. Providers must reevaluate the standard of care due to the state bans on the medication. According to Negrón et al., (2023), MTX has been one of the main treatments for rheumatoid arthritis. This medication has proved effective and is also used as combination therapy. The ban on the medication has enlisted fear in patients and concern for the providers caring for them. It has also created health inequity for female patients in comparison to male patients. “In conclusion, the combination of biological sex and state of residence could condition the use of MTX” (Negrón et al., 2023). THE DOBBS DECISION 20 According to Neman & Humphrey (2023), it is unclear to providers whether or not their patients becoming pregnant while taking a teratogenic medication, such as Isotretinoin, would fall under the legal exemptions of an abortion. With uncertainty, many providers have felt limited in their prescriptive authority for female patients seeking Isotretinoin and other medications for dermatologic conditions (Neman & Humphrey, 2023). Infertility Specialists Some restrictive abortion laws have created uncertainty surrounding their application to other aspects of healthcare. One example of the potential impact of these restrictive abortion laws is their application to in-vitro fertilization (IVF). IVF is the process of retrieving eggs from the mother, fertilizing the eggs with sperm in a lab to create embryos and transferring the embryo into the mother’s uterus, in hope of a successful implantation and pregnancy (IVF (In Vitro Fertilization), n.d.). Unused embryos are often discarded due to lack of need from parents (What To Do With Frozen Embryos After IVF, n.d.). A retrospective study spanning 2000 – 2020 found that over 50% of the 615 cases reviewed included discarded unused embryos (Alexander et al., 2020). In states where the beginning of life is defined as fertilization, potential issues arise with IVF and whether discarding unused embryos is deemed to be an abortion. This shows the unclear place IVF has in states with restrictive abortion laws. Without certainty as to the application of a particular state law on the disposal of embryos, infertility specialists may refuse to perform IVF procedures in light of potential criminal charges. When providers feel they cannot perform medical procedures or are unsure if it is legally allowed to perform a medical procedure, the real impact is to the care of patients in states with these stringent laws (Machalow, 2023). These changes in legality, based on how life is defined, may drastically change IVF practice for providers and patients. THE DOBBS DECISION 21 Patient Impacts The potential consequences for patients in states with restrictive abortion laws are far-reaching and are not limited to women seeking abortions. It would be impossible for the scope of this paper to describe every intended and unintended consequence of the Dobbs decision. Some consequences will still be developing for years to come, and the consequences of restrictive abortion legislation will likely not be fully understood for many years. Seven specific consequences will be discussed in depth: patient travel times, maternal mortality, mental health, sexual assault victims, ethnic disparities, socioeconomic impacts, and cancer care. Increased Travel Times and Implications for Reproductive Care Before the Dobbs decision, there were approximately 749 abortion clinics in the U.S., with a mean travel time of 42 minutes to access abortion, with 14% of women living over an hour from an abortion facility (Rader et al., 2022). After the Dobbs decision, the number of abortion clinics decreased to approximately 671, with an increase in mean travel time to 161.5 minutes to access an abortion facility and 30% of women living over an hour from their nearest abortion facility (Rader et al., 2022). The closure of local abortion facilities, and the need to travel is concerning because women who must travel further for abortion face increased hardships and difficulty accessing abortion services (Addante et al., 2021). Patients’ access to an abortion facility impacts the rate of abortions. Even before the Dobbs decision, “greater travel distances to abortion services were associated with lower abortion rates” (Thompson et al., 2021, p. 1). When examining the number of abortion-seeking patients, it is essential to note that the 14 states where abortion is restricted accounted for 113,000 abortions in 2020, 12% of all U.S. abortions (Maddow-Zimet et al., 2023). With THE DOBBS DECISION 22 restrictions in place, those same patients would be unable to access the care they received in their home state and would need to travel. With the massive increases in travel times and the number of patients leaving their states to obtain abortion care, these rates will likely be further impacted and reduced. For example, in Texas, following the Dobbs decision, there was both a significant decrease in abortions performed within Texas and an increase in Texans leaving the state for an abortion and an overall decrease in total abortions for Texans (White et al., 2022). Distance and time are not the only factors limiting a patient’s ability to travel. Patients who lack funds or are unable to take time off from work, especially those in poverty, are two additional limiting factors impacting the ability to have an abortion (Harned & Fuentes, 2023). Patients must also navigate complicated, evolving state laws discussed earlier to determine where they can receive services based on their location and gestational age. They must also then secure an appointment time and funds as they coordinate their travel, lodging, childcare, transportation, time off work, a person to drive them to and from their procedure, and other logistical situations that may arise (Addante et al., 2021). These can be timely and increase the risk of gestational age progressing to the point where a patient may become ineligible for services while coordinating their travel (Upadhyay et al., 2022). Before the Dobbs decision, there were still gestational age restrictions at facilities for abortions that varied by state, which required people to travel to receive an abortion if they were later in their pregnancy. A pre-Dobbs study published in 2022 examined reasons why 231 women were denied an abortion due to exceeding gestational age limits and found that 58% listed travel and procedure costs, 48% did not detect pregnancy early enough, 34% did not know THE DOBBS DECISION 23 where to get an abortion, and 30% did not know how to get a provider (Upadhyay et al., 2022). Additional reasons were waiting for an appointment, opposition from family or friends, being in jail, needing to obtain identification documents, weather, fear of protestors, getting time off work, and lack of childcare (Upadhyay et al., 2022). Post-Dobbs, there are still gestational limits in non-restricted states patients travel to; the same delays to travel may negatively impact women seeking abortions and make them ineligible for abortion as their pregnancy progresses. Further, there are impacts on abortion clinics surrounding restricted states due to their influx of new patients. To examine some surrounding states and how the Dobbs decision has impacted them, the Guttmacher Institute compared abortion numbers in states neighboring restricted states between 2020 and 2023. Colorado had an 89% increase in abortion rates, New Mexico (N.M) had an increase of 220%, Washington had an increase of 36%, and South Carolina had a 124% increase (before their August 2023 6-week abortion ban was in place) (Maddow-Zimet et al., 2023) Five clinics in New Mexico were examined following the Dobbs decision relating to their potential increase in patient load; wait times reached over three weeks, and some clinics were so booked, they could not book any new appointments (Sanger-Katz et al., 2022). Similar situations are possible in other clinics receiving traveling patients, negatively affecting abortion access to both local and traveling patients, and overwhelming clinics and staff in non-restricted states (Bui et al., 2022). THE DOBBS DECISION 24 Maternal Mortality Maternal mortality rates in the U.S. are strikingly high, ranking 122/186 of the countries studied (Maternal Mortality Ratio, n.d.). Furthermore, the U.S. ranks the highest in maternal mortality from avoidable causes in all high-income countries (Health and Health Care for Women of Reproductive Age, 2022). Post-Dobbs, restrictive abortion laws will only further increase the rate of maternal mortality in the U.S. Some mistakenly assume restrictive abortion laws will decrease the number of abortions. If a woman is seeking an abortion and is denied, she will likely try other means to complete the abortion. “Unsafe abortion is a leading – but preventable – cause of maternal deaths and morbidities. It can lead to physical and mental health complications and social and financial burdens for women, communities, and health systems” (Abortion, 2021). After the ruling of Roe v. Wade, the U.S. experienced a reduction of deaths in mothers from abortions performed by unlicensed providers as women were now seeking safe abortion care from medical providers (“Why Restricting Access to Abortion Damages Women’s Health,” 2022, p. 1). Prohibiting abortions will increase the risk of maternal mortality as women turn to less safe abortion practices when legal options are not available (“Why Restricting Access to Abortion Damages Women’s Health,” 2022). An abortion performed under the direction of a license and well-trained provider is a safe intervention. Additionally, countries with more flexible abortion laws have lower rates of maternal mortality overall, “after accounting for the GDP per capita and secular downward trends of maternal mortality” (Latt et al., 2019, p. 5). A woman in the United States is fourteen times more likely to die as a result of carrying a pregnancy than to die from having an abortion (Foster, 2020). In addition, other consequences of an unsafe abortion can put a more significant toll on THE DOBBS DECISION 25 the healthcare system as the patient may require intensive care and prolonged support in hospitals. Criminalizing and restricting access to abortion will increase maternal mortality because “abortion is far safer than childbirth” (Harris, 2022, p. 2063). Sexual Assault Victims One unexpected consequence of the Dobbs decision and subsequent restrictive abortion laws is the impact on the identification of victims of sexual assault. Some states do not have abortion exceptions allowing abortion for victims of sexual assault, including rape and incest. Furthermore, if a restricted state does have an exception for rape and incest, many states do not also consider sex trafficking to be an exception for abortion (Ross, 2022). Sex trafficking often involves the use of force and coercion, similar to rape and incest. Qualifying for an exception for rape or incest is not an easy task, and there is significant underreporting of sexual assault crimes. A woman must typically report the sexual assault to law enforcement, which creates yet another barrier for women. Women are often scared to report sexual assault crimes “due to fear of retaliation, shame, reporting an incident to officials who will not respond adequately, not wanting friends or family to know, fear of the justice system, or other personal reasons” which results in severe underreporting of these crimes (Felix & Sobel, 2023). With the combination of the barriers and fear surrounding reporting sexual assault, a woman is at risk of missing the often short time interval she could have a legal abortion in those states with an applicable exception. For example, North Dakota allows an abortion exception for rape and incest but only six weeks after the woman’s last menstrual period (State Bans on Abortion Throughout Pregnancy, 2023). Further worsening the scope of the problem is that even in states with sexual assault exceptions, some women may still have difficulty getting an abortion in severely restricted states where qualified providers have left (Felix & Sobel, 2023). THE DOBBS DECISION 26 The consequences of sexual assault are far-reaching. A study investigating the many physical and mental consequences survivors face during and after sex trafficking found that many women sought an abortion during their time in sex trafficking (Lederer & Wetzel, 2014, p.13). In one study, 55.2% of victims of sex trafficking reported having one abortion, and 29.9% reported having more than one abortion during the time they were being trafficked, with one woman reporting seventeen abortions (Lederer & Wetzel, 2014, p. 13). It is of note that the researchers anticipated the underreporting of abortions in the study. These statistics highlight an important application for healthcare workers, such as OB-GYNs or staff in women's health or abortion clinics, which have a unique opportunity to identify and intervene to help these women. There is an argument that many of these abortions may be being performed without the oversight of a provider. However, the study found that sex trafficking victims most often sought abortions in healthcare clinics (Lederer & Wetzel, 2014, p. 79). Figure 4 Where Sex Trafficking Victims Sought Abortions Where abortions were performed % Identifying site (N=37) Clinic 67.6% Hospital 16.2% Other 13.5% Different sites at different times 2.7% Note. From “The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities,” by Lederer, L. J., and Wetzel C. A., 2014, Annals of Health Law, 23, p. 79, showing where sex trafficking victims have abortions performed 87.8% of sex trafficking victims reported having some contact with healthcare during their time being trafficked. Encounters in an emergency department or hospital (63%) and Planned Parenthood (29.6%) clinics were found to be the most common type of contact a victim THE DOBBS DECISION 27 had with the healthcare system during their time being trafficked (Lederer & Wetzel, 2014, p. 77). Criminalizing abortions removes a critical opportunity to identify and help victims of sexual assault through contact with the healthcare system. One of the significant problems with not allowing victims of sexual assault to have an abortion is the continued lack of bodily autonomy they face even after the abusive situation. The ability to control their body and future can be crucial to moving on (Ross, 2022). Not allowing abortions for victims of sexual assault also further places them in danger as it may keep them in dangerous situations if their abuser is also the father of the child (Ross, 2022). This tie to an abuser can place a mother and child in lifelong danger. Amanda Gregory, a licensed clinical professional counselor, said, “Being forced to give birth will strip survivors of relational agency and could place them in unsafe situations, leading them to stay with abusive partners because they are forced to carry a pregnancy to term; and even if they leave their abusive relationships, giving birth to a child could nevertheless conscript many of them to frequent contact with their abusers for many years to come” (Gregory, 2022). Finally, Michele Goodwin, a law professor and a victim of sexual violence herself, says, "One of the key steps of being a survivor is to be able to get your freedom back, to be able to get your autonomy back, to be able to get your decision-making back” (Rape Exceptions to Abortion Bans Were Once Widely Accepted. No More, 2022). In summary, restrictive abortion laws can decrease the identification and interventions to help victims of sex trafficking, rape, and incest in the healthcare setting, decrease bodily autonomy for these women, and place these women at greater risk of staying with an abusive partner due to sharing a child. Changes to decrease the barriers victims of rape and incest face when trying to be approved for an abortion exception are essential to improve their access to safe THE DOBBS DECISION 28 and timely healthcare. Policymakers should be made aware of the circumstances surrounding sex trafficking and that it is often not a choice the women are making to be a part of sex trafficking, and they are often victims that deserve exemption consideration, like the cases of rape and incest. Mental Health Some proponents of restrictive abortion laws have justified denying abortion because they believe an abortion has a negative impact on a woman's mental health. A literature review completed by the Task Force on Mental Health and Abortion from The Council of Representatives of the American Psychological Association found that there are factors that increase the risk of mental health problems following an abortion, including: Perceptions of stigma, need for secrecy, and low or anticipated social support for the abortion decision; a prior history of mental health problems; personality factors such as low self-esteem and use of avoidance and denial coping strategies; and characteristics of the particular pregnancy, including the extent to which the woman wanted and felt committed to it. (Major et al., n.d.) A history of mental health issues was the strongest indicator of mental health issues after an abortion (Major et al., n.d.). The authors did note that these factors listed above are also related to adverse mental health outcomes for many different stressors, even birth or motherhood, and were not risk factors for only mental health issues after an abortion (Major et al., n.d.). Though some women do have negative feelings or mental health issues that arise post-abortion, the studies do not support this claim as a generalization for all women and a reason to restrict abortion. One of the studies at the forefront of abortion and abortion denial research is The Turnaway Study. The Turnaway Study was a longitudinal study with close to 1,000 women from THE DOBBS DECISION 29 thirty different abortion clinics nationwide. The women were interviewed from 2008 to 2016 to compare the impact of receiving an abortion against being denied an abortion on women and their children. They conducted interviews one week after seeking an abortion and then twice yearly for five years after (Foster, 2020). The data gathered as part of The Turnaway Study continues to prove beneficial as it has been used in a number of subsequent studies. One study used interview data from The Turnaway Study to compare the mental health impact of those who received an abortion compared to those who were denied an abortion (Biggs et al., 2017). They used validated scales to examine depression, anxiety, self-esteem, and life satisfaction. The study found that one week after being denied an abortion, women initially reported higher rates of anxiety and depression and lower rates of self-esteem and life satisfaction compared to women who received an abortion (Biggs et al., 2017). Six months after either the performed abortion or abortion denial, these same areas of mental health level out between the groups. These results suggest that both groups have a similar long-term mental health impact. In fact, a completed abortion appears to be less harmful to a woman’s mental health than being denied an abortion (Biggs et al., 2017). Another study using The Turnaway Study data examined the “changes in emotions and abortion decision rightness over time” (Rocca et al., 2020). They found that, five years later, 99% of 667 women who had an abortion in the study felt they made the right decision. They found that the women’s positive and negative emotions regarding their abortion both declined over the five years. Finally, they found that after five years, “relief was the most commonly felt emotion” (Rocca et al., 2020). THE DOBBS DECISION 30 Figure 5 Post-abortion sadness, regret, guilt, anger, relief, and happiness, over five years Note. From “Emotions and decision rightness over five years following an abortion: An examination of decision difficulty and abortion stigma,” by Rocca et al., 2020, Social Science and Medicine, 248, p. 5, showing trends in emotions over five years of individuals that received an abortion. Racial and Ethnic Disparities In society and the healthcare industry today people of color, including migrants and American-born citizens, are at a disproportionate disadvantage when it comes to healthcare in the United States. “Decades of research indicate that there is something unique about being Black and pregnant in the United States, as foreign-born Black individuals have better obstetric outcomes than U.S.-born Black birthing [women]” (Treder et al., 2023). Treder et al. (2023) discovered “Black [women] at the highest income levels have pregnancy-related mortality rates comparable to White [women] with the lowest income levels” (2023). This is not even specific to Black people only. In general, there has shown to be a 1.7 to 2.1-fold increase of maternal THE DOBBS DECISION 31 morbidity among Black and American Indian women, when compared to their White counterpart (2023). For every 100,000 Black births, 55.3 of those women will suffer mortality. When compared to their White counterparts, this rate is nearly three times the White’s (19.1 per 100,000 births) (Treder et al., 2023). Now consider the fact that, on average, the abortion rate for Black women is 27.1 per 1000, the highest among all races in the United States (Jones et al., 2022). If people of color are already at an disproportionate risk of receiving poorer quality and less safe healthcare in the United States, and are already experiencing some of the highest abortion rates, it can be deduced that overturning the federal right to abortion (The Dobbs decision) is likely to worsen an already difficult situation. Approximately 6.5 million Latinx and Hispanic individuals, and 57% of the entire Black population in the United States, now live in a state that has either banned abortion already, or is anticipated to do so in the coming months and years (Treder et al., 2023). “In the 26 states where abortion has been banned post-Dobbs or is expected to be banned, maternal mortality is estimated to increase by up to 29%” (Treder et al., 2023). Put simply, abortion restrictions will have a direct, negative, impact on maternal mortality, and those already experiencing disproportionate care in the United States, namely women of color, will ultimately suffer the most (Treder et al., 2023). Socioeconomic Impacts The right to abortion, or the lack thereof, plays into the socioeconomic well-being of all women, and their families, regardless of their socioeconomic status prior to becoming pregnant. 50% of women seeking an abortion live below the Federal Poverty Level (FPL), and 75% struggle to provide for basic necessities, such as food, housing, and transportation (Foster et al., THE DOBBS DECISION 32 2022). Foster et al. (2022) researched the impact of receiving an abortion, or being denied an abortion, and what happens to these women’s financial lives thereafter (2022). The results of this study revealed that, even after considering other factors influencing a woman’s socioeconomic status, there were significant differences in the outcomes between women who were permitted to receive abortions, and those who were denied. It should be noted that programs such as those available via public assistance were key in decreasing the gap between these women, specifically for those women who were no longer able to work full-time due to being denied an abortion. Though these programs were helpful, they ultimately were not adequate in terms of keeping the entire family from living in poverty after the addition of the newborn (Foster et al., 2022). Ultimately, being denied an abortion increased the odds of a woman and her family earning an income less than the FPL by four times (Foster et al., 2022). The long-term impact of this detrimental impact several generations later needs to be evaluated, not only for a single family, but with a broad perspective into the overall consequences for the United States as a whole. Figure 6 Socioeconomic outcomes of abortion patients Note. Socioeconomic outcomes of women who were and were not able to receive an abortion (Foster et al., 2022) THE DOBBS DECISION 33 Per the graph above, over the five year period, women who were denied an abortion (Turnaway-birth and Turnaway-nobirth) experienced noticeable trends in economic outcomes. Also note the upward trend in economic status in those who were able to receive an abortion. “[W]omen who received and those who were denied an abortion were economically similar for years before they became pregnant and the negative consequences of being denied an abortion persisted for years after” (Foster et al., 2022). Foster et al. (2022) then goes on to explain how it is not only the woman who ultimately suffers from this dramatic impact, but also those with whom the woman lives, including any other children she may have, her spouse or partner, and other family members (2022). This also does not consider the fact that the average net cost to the patient for an abortion (after insurance) is $634 (Dickman et al., 2022). This significant cost will translate into an increased number of women seeking unsafe alternatives. Foster et al. (2022) said the following regarding abortions and safety in the future: In the coming years, it is critical that the public health community act to mitigate the harms of further restrictions to health care. We will need to know who is most at risk for attempting dangerous methods of inducing abortion and who forgoes treatment of spontaneous and induced abortion complications for fear of legal repercussions. Identifying successful harm reduction strategies will be key. Finally, many women in The Turnaway Study stated they were seeking an abortion for financial reasons, specifically, to continue adequately caring for the children they already had (Foster, 2020). Many of these women have good intentions in seeking an abortion in order to provide for, and protect their current children by not placing them in difficult financial situations. The Turnaway Study found that the existing children of mothers who had recently been denied an abortion had lower child development scores overall and had more socioeconomic struggles than THE DOBBS DECISION 34 the other group, which could be related to the lower development scores (Foster et al., 2019). Again, the impact of restrictive abortion laws is far-reaching, even impacting living children in negative ways. Cancer Care “Cancer during pregnancy is relatively uncommon, occurring [in] 0.02-0.1% of all pregnancies… However, this translates into approximately 6,000 pregnant women receiving a diagnosis of cancer each year worldwide” (Fancher et al., 2019). One can only speculate as to the emotions, thoughts, and feelings a pregnant mother would experience after a cancer diagnosis is made during pregnancy. At some point, the mother, father, and other loved ones would ultimately have to ask themselves one of the following questions: ‘Should we terminate the pregnancy in order to receive appropriate, and well-researched treatment? Do we proceed with the pregnancy and cancer treatment, understanding that this carries significant risks to the fetus and the mother?’ These questions are very serious and ethically challenging, with some believing they were not fully examined prior to passing restrictive abortion laws. While it is recognized that the sole purpose of the Supreme Court is to rule whether abortion is, or is not, a constitutional right, this does need to be seriously considered at the state and federal legislative levels. Fancher et al. (2019) provides some information regarding chemotherapy use during pregnancy: 1) There are two main factors to consider when evaluating the use of chemotherapy during pregnancy: the drug being used, and the gestational age of the fetus. 2) Chemotherapy agents are typically composed of low molecular weight molecules, allowing them to cross the placenta. 3) The timing of chemotherapy is key with regards to fetal malformation, with an approximate 20% risk when administered during the first trimester, and 1% risk thereafter with THE DOBBS DECISION 35 an associated increased risk of issues such as IUGR, low birth weight, and other organ abnormalities, malformations, and dysfunctions (2019). While a drop from 20% down to 1% (after 13 weeks) is significant, and surely welcomed news to families hoping to continue with pregnancy during cancer treatment, 1% is not 0% and the possibility of malformation or deformity is most certainly present. Additionally, a woman needing to receive chemotherapy prior to the 13 week mark carries that 20%, 1-in-5, risk of “spontaneous abortion, fetal death, and major congenital malformation” (2019). Approximately 93% of abortions that take place in the United States occur prior to 13 weeks gestation (Roncoroni et al., 2023). According to Roncoroni et al. (2023), in most cases when a woman receives an abortion after the 13th week, it is typically as a result of medical conditions, diagnoses, or complications thereof. This is especially the case when the fetus is evaluated in-utero and is determined to be non-viable, or if the continuation of the pregnancy places the woman’s life at risk (Roncoroni et al., 2023). The medical community has made great strides in cancer treatment over the past two to three decades. However, the ethical dilemma of performing research on pregnant women, makes performing research, with them as the subject, rare and “pregnant patients are almost universally excluded from participating in drug trials due to the possibility of harm to the fetus” (Fancher et al., 2019). Thus, due to lack of research, not leaving many options to pregnant women with a cancer diagnosis. This ‘harm’ ought to be compared to the potential ‘harm’ done to the mother and/or fetus with a cancer diagnosis should the mother decide to continue with cancer treatment while pregnant. Additionally, seeing as an individual receiving a cancer diagnosis during pregnancy is low (0.02-0.1%), it can be difficult to ensure large-enough cohorts to weed out select outliers (Fancher et al., 2019). THE DOBBS DECISION 36 While there is evidence to suggest that after the first trimester, the risk of harm to the fetus is significantly reduced, there is also evidence to suggest “that pregnancy hormones might accelerate the growth of certain cancers, such as thyroid cancer” (Gourd, 2022). The majority of cancers during pregnancy consist of “cervical, breast, melanoma, or Hodgkin’s lymphoma” (Fancher et al., 2019). Each of these, and all other cancers, is best managed with early detection and treatment. If a woman is in her first trimester and a cancer diagnosis is made, some might assume that the woman is to wait until the second or third trimester to obtain treatment, thus delaying her treatment and likely worsening her outcome and prognosis solely to reduce risk of harm to the fetus. The life of the fetus is then placed at a higher priority than the mother’s. If the right for a woman to make this decision has been overturned or revoked at the federal level, this leaves many women, their partners, family, and their medical providers in a situation that is not conducive to doing no harm. The Dobbs decision has had a significant impact on the treatment and medical care that cancer patients can receive during pregnancy. The ability for a woman to receive an abortion entails more than the stereotypical woman in her twenties receiving an elective abortion for personal reasons. Gourd (2022) put it best, saying “the effect of [this] ruling…deprioritise[s] the health of [a] mother to protect the unborn child…Abortion is a complex issue and the overturning of Roe vs Wade has failed to appropriately acknowledge the medical and social exceptions, and most crucially, the health and welfare of the mother” (2022). Future Implications The full extent of future implications of the Dobbs decision and the associated restrictive abortion laws may not be fully understood for years. The impact of this policy change is likely to be extensive. Three future implications will be discussed in depth: contraception access and THE DOBBS DECISION 37 research, government assistance for parents and families, and comprehensive sexual education in schools. Contraception Access to contraception is an essential part of healthcare. The Turnaway Study found that 40% of women who wanted an abortion had difficulty getting contraception (Foster, 2020). In countries outside of the U.S., there are more options available for over-the-counter hormonal birth control. One benefit that could arise from the Dobbs decision is that more attention and research will be devoted to contraception methods (Rutherford, 2023). If abortions are restricted, contraception must improve to meet the needs of women and their families. The focus could be on increasing male contraception options, decreasing the side effects of hormonal contraception, and making hormonal contraception more easily attained. A sign of progress is that as of July 2023, the FDA has approved an over-the-counter hormonal contraception option called Opill, which is a progesterone-only hormonal contraception (Research, 2023). It is anticipated to be available in stores beginning in 2024. Though this is encouraging for improved access to contraceptive healthcare for women, there are significant concerns related to contraception access and legality after the Dobbs decision. One concerning implication is whether contraception methods that block implantation are considered abortion. “Social conservatives want to change the definition of pregnancy so that it begins at fertilization—instead of at implantation” (Machalow, 2023, p. 110). This definition of the beginning of life would impact things like intrauterine devices (IUD) as these devices work mainly by preventing implantation instead of fertilization. Meaning, if life begins at fertilization, then an IUD could be considered an abortion. With a 99% effectiveness rate and multi-year use, IUDs are one of the most effective contraception options available (How Effective Is THE DOBBS DECISION 38 Contraception at Preventing Pregnancy?, 2017). Further limiting the contraceptive options for women is another hit to the bodily autonomy of women. Clinicians must be involved in policy creation to understand the nuances these definitions have on medical practice and the care patients can receive. Currently, “The right to contraception is protected by two Supreme Court cases: the landmark 1965 ruling in Griswold v. Connecticut, which found that married couples had the right to use birth control, and a subsequent 1972 ruling in a case known as Eisenstadt v. Baird, which extended that protection to unmarried people” (Luthra, 2022). After the Dobbs decision, there are concerns that contraception could quickly become another target for restrictive laws next. For example, in the spring of 2022, a bill in Louisiana was proposed that could have “criminalized IUDs and emergency contraception” (Luthra, 2022). The consequences of the Dobbs decision and restrictive abortion laws will likely impact many other areas of healthcare and social issues than just abortion access. Government Assistance Another area that must be addressed if restrictive abortion laws are to remain in place is how the government and associated policies are supporting parents after the birth of children. Using the data from The Turnaway Study, a subsequent study found that 40% of women stated they were seeking an abortion for financial reasons, making it the most common reason women were seeking an abortion (Biggs et al., 2013). “The U.S. is the only country among 41 nations that does not [nationally] mandate any paid leave for new parents” (Livingston & Thomas, 2019). Not only is a lack of mandated parental leave an area of concern, but the United States also ranks low on financial support for childcare. “In the developed world, the United States is an outlier in its low levels of financial support for young children’s care” (Miller, 2021). It is THE DOBBS DECISION 39 reasonable to assume that if a state mandates that a woman carry a pregnancy to term, there should be systems in place to support her in raising the child. The U.S. does have some systems in place to support parents, including The Special Supplemental Nutrition Program for Women, Infants, and Children, Temporary Assistance for Needy Families, The Vaccine for Children Program, and mandates that insurance companies must cover a breast pump for expecting mothers. However, more programs and initiatives are needed to support parents and families adequately. Advocacy on this topic should be specifically aimed at increasing access to, and time of, parental leave, and making childcare more accessible and affordable. To be pro-life should also include supporting the lives of the families after the birth of children. Comprehensive Sexuality Education State and Local Legislation As mentioned by Planned Parenthood (n.d.), funding and restrictive bills about sex education for schools are decided by state and local governments. The states have the authority to decide how much funding, if any, is granted to sex education programs. “The federal government also continues to provide funding for abstinence-only-until-marriage (AOUM) programs” (Planned Parenthood. n.d.). A study done by Fox et al. (2019) found that federal abstinence-only funding did not decrease birth rates but showed an inverse effect, which meant that these programs increased adolescent birth rates in conservative states (Fox et al., 2019). Healthcare providers have concerns that many adolescents will become pregnant in a restrictive abortion state before learning medically correct information about their bodies. “Fewer than half of high schools and only a fifth of middle schools are teaching the sexual health topics that the Centers for Disease Control and Prevention (CDC) considers “essential” for healthy young people” (Planned Parenthood, n.d.). Additional research is needed to be done to THE DOBBS DECISION 40 understand how many restrictive abortion states also have abstinence-based sexuality education. Utah is one of these states with restrictive abortion laws and an abstinence-based sexuality education program, and will be used as an example. According to the Sexuality Information and Education Council of the United States (SIECUS) (2023), the current guidelines for Utah schools require that sex education is taught at least twice between grades 8 and 12. “Curriculum is not required to be comprehensive and must stress abstinence” (SIECUS, 2023). SIECUS (2023) also includes that the curriculum must be medically accurate. Parents or guardians may give written permission for students not to engage in sex education during their time in school (SIECUS, 2023). For the adolescents who are excluded from formal sex education in school, the parents are expected to provide education. Many parents are avoiding conversations about sex or are filtering their conversations about sex to minimal conversation. As mentioned by Ritchie (2016), many adolescents get most of their information about sex from their peers and the Internet, including pornography, which causes adolescents to learn or assume misleading information and use vulgar terms rather than anatomically correct terms. Usually, the first time Utah teens learn correct anatomical terms will be with physical exams with their healthcare providers due to the lack of education from Utah schools and Utah parents. Comprehensive sex education (CSE) is a strategy to give adolescents more information about their bodies and sexuality. Abstinence programs are ineffective at preventing adolescents from engaging in premarital sex. Up to 57% of high school students have engaged in sex before high school graduation, as shown in Figure 7. THE DOBBS DECISION 41 Figure 7 Percentage of Students who Reported Having Sexual Intercourse Note. This graph shows the percentage of high school students who have engaged in sex organized by grade. From Guttmacher Institute, 2021. (https://www.guttmacher.org/fact-sheet/sex-education). Copyright 2021 by Guttmacher Institute. Having this education system in place in a restrictive abortion state does not give adequate information for adolescents to make prepared decisions about the relationship between sexual activities causing pregnancy and other complications. Restrictive states providing abstinence education in schools poses an active problem for the state's adolescents. Young people are not getting the sex education they need: About half of adolescents (53% of females and 54% of males) reported in 2015–2019 that they had received sex education that meets the minimum standard articulated in Healthy People 2030; among teens reporting penile-vaginal intercourse, fewer than half (43% of females and 47% of males) received this instruction before they first had sex. (Guttmacher Institute, 2022) THE DOBBS DECISION 42 Both male and female adolescents lack the education necessary to prevent pregnancy, including contraception, pregnancy likelihood, and risks with sex behavior. "6.1% of Utah secondary schools taught students how to correctly use a condom in a required course in any grades 6, 7, or 8" (SIECUS, 2023). If abstinence-based programs do not include this information, teens are not making decisions understanding the risks associated including pregnancy. Many adolescents who become pregnant have not been taught about pregnancy and pregnancy symptoms so the majority will fall outside of the abortion exemption of 17 weeks. Sexuality Education Proposed Program for Restrictive Abortion States Adolescents need comprehensive sex education in school for adequate pregnancy prevention, considering the restrictive abortion laws. A study reviewed by Guttmacher Institute (2021), commissioned by the United Nations, found that comprehensive sex education programs had a positive effect on adolescents and results included delayed initiation of sex, decreased frequency of sexual intercourse, fewer sexual partners, and increased use of condoms and other contraceptives. Utah and other restrictive states need to consider comprehensive sex education in school age adolescents due to the Dobbs decision and recent changes in abortion regulation. The information provided is essential to prevent teen pregnancy. “Research shows that federal abstinence-only funding does not lower adolescent birth rates. In fact, the more that state policies emphasize abstinence-only programs, the higher the incidence of adolescent pregnancies and births” (Guttmacher Institute, 2021). The most up to date evidence suggests that comprehensive sex education is more effective than abstinence only education in preventing pregnancy. “There are currently no federal programs dedicated to funding and expanding access to comprehensive sex education, which is THE DOBBS DECISION 43 considered the gold standard of sex education” (Guttmacher Institute, 2021). Federally funded programs may make comprehensive sex education more readily available to US adolescents. Conclusion In conclusion, this paper has discussed some of the consequences and implications from the Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization (2022) decision and the associated restrictive abortion legislation. This decision of the Supreme Court stated there was no constitutional right to abortion and that the people have the power to decide the abortion laws at either a state or federal level. It would be impossible for the scope of this paper to include all consequences related to restrictive abortion laws, and due to the recent nature of the Dobbs decision and state law changes, many consequences are not fully realized and will likely not be for decades. What is known now is that there will be consequences, and they are severe and far-reaching. This paper investigated the current access to abortion available in the U.S. It highlighted multiple negative impacts of restrictive abortion laws on providers and patients that merited closer examination and demonstrated the various health risks to patients and legal dilemmas for healthcare providers. As discussed, restrictive abortion laws are not likely to decrease abortion rates in the U.S. More research is needed to improve contraception options and provide youth with comprehensive sexuality education to prevent unwanted pregnancy and subsequently decrease abortion rates. It is clear from the research that medical professionals must be included in creating legislation involving healthcare. Only through the experiences of those working firsthand with patients seeking an abortion can one understand the scope of the issue. Areas of future research should include the impact of the Dobbs decision and restrictive abortion laws on children born from unwanted pregnancies, the importance of having healthcare THE DOBBS DECISION 44 providers included in the legislation creation to ensure the highest level of patient safety, and the success rates of medically necessary abortions if OB-GYN students and providers have less experience with the procedure. Restricting the autonomy of individuals is a slippery slope. The autonomy of women to decide the course of their lives and their healthcare is a private matter. Medical providers in all fields should advocate for access to abortion care for women. Medical doctors, physician assistants, and nurse practitioners have been uniquely aligned with common concerns with practicing medicine in light of restrictive abortion laws and the negative impact on patient safety. Currently, there is a lack of clarity in some states surrounding what is restricted in each state and how a woman can get a desired or needed abortion. A matter as serious as abortion merits a higher level of clarity. The most effective way to ensure equal access to abortion care for all women would be a federal law approved through Congress and signed by the president. A federal law could create a nationwide standard with clear guidelines on who and when a woman can receive an abortion. A federal law could be created with the help of many different medical providers with first-hand knowledge of the medical necessity of abortion access and researchers who have studied the risks of abortion denial. Ultimately, “Facts are very important, especially when discussing the health of women and the American public. The fact is, abortion is an essential component of women’s health care” (Abortion Is Healthcare, n.d.). The consequences of the Dobbs decision are significant and extensive. Changes must be made to abortion legislation nationwide to ensure the safety and equity of women in the United States of America. THE DOBBS DECISION 45 References Abortion. (2021, November 25). World Health Organization. https://www.who.int/news-room/fact-sheets/detail/abortion Abortion Is Healthcare. (n.d.). https://www.acog.org/advocacy/facts-are-important/abortion-is-healthcare Abortion Laws by State. (n.d.). Center for Reproductive Rights. https://reproductiverights.org/maps/abortion-laws-by-state/ Addante, A. N., Paul, R., Dorsey, M., McNicholas, C., & Madden, T. (2021). Differences in Financial and Social Burdens Experienced by Patients Traveling for Abortion Care. Women’s Health Issues, 31(5), 426–431. https://doi.org/10.1016/j.whi.2021.06.002 Alexander, V. M., Riley, J. K., & Jungheim, E. S. (2020). Recent trends in embryo disposition choices made by patients following in vitro fertilization. Journal of Assisted Reproduction and Genetics, 37(11), 2797–2804. https://doi.org/10.1007/s10815-020-01927-y ​Baden, K., Curhan, T., & Dreweke, J. (2023, October 4). In the First Month After North Carolina’s Latest Abortion Restrictions, Facility-Based Abortions Dropped by 31%. Guttmacher Institute. https://www.guttmacher.org/2023/10/first-month-after-north-carolinas-latest-abortion-rest rictions-facility-based-abortions Bazargan, M., Cobb, S., & Assari, S. (2021). Discrimination and Medical Mistrust in a Racially and Ethnically Diverse Sample of California Adults. Annals of Family Medicine, 19(1), 4–15. https://doi.org/10.1370/afm.2632 Bendix, A. (2022, June 30). Abortion ban exceptions: What legally constitutes a THE DOBBS DECISION 46 “life-threatening emergency”? NBC News. https://www.nbcnews.com/health/health-news/abortion-ban-exceptions-life-threatening-pre gnancy-rcna36026 Biggs, M. A., Gould, H., & Foster, D. G. (2013). Understanding why women seek abortions in the US. BMC Women’s Health, 13, 29. https://doi.org/10.1186/1472-6874-13-29 Biggs, M. A., Upadhyay, U. D., McCulloch, C. E., & Foster, D. G. (2017). Women’s Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study. JAMA Psychiatry, 74(2), 169–178. https://doi.org/10.1001/jamapsychiatry.2016.3478 Boudy, A.-S., Zaccarini, F., Selleret, L., Arfi, A., Guiggi, I., Touboul, C., Bendifallah, S., & Darai, E. (2020). Oncological management of pregnancy-associated cancers: Analysis from the French CALG (Cancer Associé à La Grossesse) network. Acta Oncologica, 59(9), 1043–1050. https://doi.org/10.1080/0284186X.2020.1767300 Bui, Q., Miller, C. C., & Sanger-Katz, M. (2022, June 24). How Abortion Bans Will Ripple Across America. The New York Times. https://www.nytimes.com/interactive/2022/06/24/upshot/dobbs-roe-abortion-driving-distanc es.html Cohen, D. S., Donley, G., & Rebouché, R. (2023). Abortion Shield Laws. NEJM Evidence, 2(4), EVIDra2200280. https://doi.org/10.1056/EVIDra2200280 Coleman-Minahan, K., & Alspaugh, A. (2022). Abortion Knowledge Among Advanced Practice Clinicians in Colorado. Women’s Health Issues, 32(5), 461–469. https://doi.org/10.1016/j.whi.2022.04.006 Constitution of The United States of America - GovInfo. Amendments to the Constitution of The THE DOBBS DECISION 47 United States of America, www.govinfo.gov/content/pkg/GPO-CONAN-1992/pdf/GPO-CONAN-1992-6.pdf. Counseling and Waiting Periods for Abortion. (2023, August 30). Guttmacher Institute. https://www.guttmacher.org/state-policy/explore/counseling-and-waiting-periods-abortion De Rocco, S., Buca, D., Oronzii, L., Petrillo, M., Fanfani, F., Nappi, L., Liberati, M., D’Antonio, F., Scambia, G., Leombroni, M., Dessole, M., & Lucidi, A. (2022). Reproductive and pregnancy outcomes of fertility-sparing treatments for early-stage endometrial cancer or atypical hyperplasia: A systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology, 273, 90–97. https://doi.org/10.1016/j.ejogrb.2022.04.019 Dickman, S. L., White, K., Sierra, G., & Grossman, D. (2022). Financial Hardships Caused by Out-of-Pocket Abortion Costs in Texas, 2018. American Journal of Public Health, 112(5), 758–761. https://doi.org/10.2105/ajph.2021.306701 Ethics of chemotherapy during pregnancy., (Oxford University Press / USA February 15, 2019). http://ezproxy.westminsteru.edu/login?url=https://search.ebscohost.com/login.aspx?direct=t rue&db=c8h&AN=134452326&site=ehost-live Fay, K. E., Diouf, K., Butler, S. K., Onwuzurike, C., Wilkinson, B. E., Johnson, N. R., Schantz-Dunn, J., & Bartz, D. (2022). Abortion as Essential Health Care and the Critical Role Your Practice Can Play in Protecting Abortion Access. Obstetrics & Gynecology, 140(5), 729. https://doi.org/10.1097/AOG.0000000000004949 Felix, M., & Sobel, L. (2023, May 18). A Review of Exceptions in State Abortions Bans: Implications for the Provision of Abortion Services. KFF. https://www.kff.org/womens-health-policy/issue-brief/a-review-of-exceptions-in-state-ab THE DOBBS DECISION 48 ortions-bans-implications-for-the-provision-of-abortion-services/ Foster, D. G. (2020). The Turnaway Study: The Cost of Denying Women Access to Abortion. Scribner. Foster, D. G. (2022). New Abortion Bans Will Increase Existing Health and Economic Disparities. American Journal of Public Health, 112(9), 1276–1277. https://doi.org/10.2105/ajph.2022.306993 Foster, D. G., Biggs, M. A., Ralph, L., Gerdts, C., Roberts, S., & Glymour, M. M. (2022). Socioeconomic Outcomes of Women Who Receive and Women Who Are Denied Wanted Abortions in the United States. American Journal of Public Health, 112(9), 1290–1296. https://doi.org/10.2105/ajph.2017.304247 Foster, D. G., Raifman, S. E., Gipson, J. D., Rocca, C. H., & Biggs, M. A. (2019). Effects of Carrying an Unwanted Pregnancy to Term on Women’s Existing Children. The Journal of Pediatrics, 205, 183-189.e1. https://doi.org/10.1016/j.jpeds.2018.09.026 ​Fox, A. M., Himmelstein, G., Khalid, H., & Howell, E. A. (2019). Funding for Abstinence-Only Education and Adolescent Pregnancy Prevention: Does State Ideology Affect Outcomes? American Journal of Public Health, 109(3), 497–504. https://doi.org/10.2105/AJPH.2018.304896 Gourd, E. (2022). Overturning Roe vs Wade undermines US cancer care. The Lancet Oncology, 23(8), 987. https://doi.org/10.1016/S1470-2045(22)00389-8 Grant, R. (2023, July 23). Group using ‘shield laws’ to provide abortion care in states that ban it. The Guardian. https://www.theguardian.com/world/2023/jul/23/shield-laws-provide-abortion-care-aid-acce ss THE DOBBS DECISION 49 Gregory, A. (2022, June 24). How Overturning Roe vs. Wade Threatens Trauma Survivors. Psychology Today. https://www.psychologytoday.com/za/blog/simplifying-complex-trauma/202206/how-ove rturning-roe-vs-wade-threatens-trauma-survivors Gruver, M. (2022, August 10). Abortion to remain legal in Wyoming while lawsuit proceeds | AP News. https://apnews.com/article/abortion-health-jackson-wyoming-constitutions-042d610059f51c 11563b0df3e78a8dc6 Guttmacher Institute. (2021, June 2). Federally Funded Sex Education: Strengthening and Expanding Evidence-Based Programs. https://www.guttmacher.org/fact-sheet/sex-education Guttmacher Institute. (2022, February 15). US Adolescents’ Receipt of Formal Sex Education. https://www.guttmacher.org/fact-sheet/adolescents-teens-receipt-sex-education-united-states Harned, E. B., & Fuentes, L. (2023, January 23). Abortion Out of Reach: The Exacerbation of Wealth Disparities After Dobbs v. Jackson Women’s Health Organization. Guttmacher Institute. https://www.guttmacher.org/article/2023/01/abortion-out-reach-exacerbation-wealth-disparit ies-after-dobbs-v-jackson-womens Harris, L. H. (2022). Navigating Loss of Abortion Services—A Large Academic Medical Center Prepares for the Overturn of Roe v. Wade. New England Journal of Medicine, 386(22), 2061–2064. https://doi.org/10.1056/NEJMp2206246 Health and Health Care for Women of Reproductive Age. (2022, April 5). The Commonwealth Fund. https://doi.org/10.26099/4pph-j894 How effective is contraception at preventing pregnancy? (2017, December 21). Nhs.Uk. THE DOBBS DECISION 50 https://www.nhs.uk/conditions/contraception/how-effective-contraception/ Hulsman, L., Bradley, P. K., Caldwell, A., Christman, M., Rusk, D., & Shanks, A. (2023). Impact of the Dobbs v Jackson Women’s Health Organization decision on retention of Indiana medical students for residency. American Journal of Obstetrics & Gynecology MFM, 5(11), 101164. https://doi.org/10.1016/j.ajogmf.2023.101164 Jones, R. K., & Jerman, J. (2022). Population Group Abortion Rates and Lifetime Incidence of Abortion: United States, 2008–2014. American Journal of Public Health, 112(9), 1284–1296. https://doi.org/10.2105/ajph.2017.304042 Kirkman, M., Apicella, C., Graham, J., Hickey, M., Hopper, J. L., Keogh, L., Winship, I., & Fisher, J. (2017). Meanings of abortion in context: Accounts of abortion in the lives of women diagnosed with breast cancer. BMC Women’s Health, 17, 1–10. https://doi.org/10.1186/s12905-017-0383-1 Kortsmit, K. (2021). Abortion Surveillance—United States, 2019. MMWR. Surveillance Summaries, 70. https://doi.org/10.15585/mmwr.ss7009a1 Krasnik, A., Bhopal, R. S., Gruer, L., & Kumanyika, S. K. (2018). Advancing a unified, global effort to address health disadvantages associated with migration, ethnicity and race. European Journal of Public Health, 28, 1-N.PAG. https://doi.org/10.1093/eurpub/cky046 Latt, S. M., Milner, A., & Kavanagh, A. (2019). Abortion laws reform may reduce maternal mortality: An ecological study in 162 countries. BMC Women’s Health, 19(1), 1. https://doi.org/10.1186/s12905-018-0705-y Lederer, L. J., & Wetzel, C. A. (2014). The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Annals of Health Law, 23. Livingston, G., & Thomas, D. (n.d.). Among 41 countries, only U.S. lacks paid parental leave. THE DOBBS DECISION 51 Pew Research Center. https://www.pewresearch.org/short-reads/2019/12/16/u-s-lacks-mandated-paid-parental-l eave/ Luthra, S. (2022, May 25). With abortion rights in limbo, conservative lawmakers are eyeing restrictions on IUDs and Plan B. The 19th. https://19thnews.org/2022/05/restrictions-birth-control-iuds-plan-b/ Machalow, D. (2023). Screwed But Not Even Kissed: The Parade of Reproductive and Economic Horribles Likely to Follow Dobbs. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.4511881 Maddow-Zimet, I., Baden, K., Jones, R. K., DoCamp, I., & Philbin, J. (2023, August 30). New State Abortion Data Indicate Widespread Travel for Care. Guttmacher Institute. https://www.guttmacher.org/2023/09/new-state-abortion-data-indicate-widespread-travel-ca re Major, B., Appelbaum, M., Beckman, L., Dutton, M. A., Russo, N. F., & West, C. (n.d.). APA Task Force on Mental Health and Abortion. Maternal mortality ratio. (n.d.). https://www.cia.gov/the-world-factbook/field/maternal-mortality-ratio/country-compariso n/ Miller, C. C. (2021, October 6). How Other Nations Pay for Child Care. The U.S. Is an Outlier. The New York Times. https://www.nytimes.com/2021/10/06/upshot/child-care-biden.html Negrón, J. B., Rodriguez-Malavé, M. J., Camacho, C. O., Malavé, C. L., & Rodríguez-Guzmán, V. M. (2023). The overturn of Roe v. Wade beyond abortion: A snapshot of methotrexate accessibility for people with rheumatic and musculoskeletal diseases—a mixed methods THE DOBBS DECISION 52 study using Twitter data. Rheumatology International. https://doi.org/10.1007/s00296-023-05407-1 Neman, S., & Humphrey, S. R. (2023). Post Roe v Wade’s Overturn: Importance and Methods of Patient-Physician Confidentiality in Conversations Surrounding Isotretinoin and Contraception in Wisconsin. WMJ : Official Publication of the State Medical Society of Wisconsin, 122(2), 88–89. Planned Parenthood. (n.d.). How Sex Education Get Funding. Retrieved November 18, 2023, from https://www.plannedparenthoodaction.org/issues/sex-education/how-sex-education-funde d Planned Parenthood. (n.d.). Sex Education Laws and State Attacks. Retrieved November 18, 2023, from https://www.plannedparenthoodaction.org/issues/sex-education/sex-education-laws-and-s tate-attacks Rader, B., Upadhyay, U. D., Sehgal, N. K. R., Reis, B. Y., Brownstein, J. S., & Hswen, Y. (2022). Estimated Travel Time and Spatial Access to Abortion Facilities in the US Before and After the Dobbs v Jackson Women’s Health Decision. JAMA, 328(20), 2041–2047. https://doi.org/10.1001/jama.2022.20424 Rape exceptions to abortion bans were once widely accepted. No more. (2022, April 8). Los Angeles Times. https://www.latimes.com/politics/story/2022-04-08/red-states-eliminate-rape-exceptions-f rom-abortion-bans Rayburn, W. F., & Xierali, I. M. (2021). Subspecialization in Obstetrics and Gynecology: Is It THE DOBBS DECISION 53 Affecting the Future Availability of Women’s Health Specialists? Obstetrics and Gynecology Clinics, 48(4), 737–744. https://doi.org/10.1016/j.ogc.2021.06.003 Research, C. for D. E. and. (2023). Opill (0.075mg Oral Norgestrel Tablet) Information. FDA. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/op ill-0075mg-oral-norgestrel-tablet-information Ritchie, M. (2016, March 25). How Are Our Children Learning about Sex? The Responsibility of Parents and Schools to Teach Kids about Human Development and How to Form Caring Relationships - Papers & Essays. Child Research Net. https://www.childresearch.net/papers/rights/2016_02.html Rocca, C. H., Samari, G., Foster, D. G., Gould, H., & Kimport, K. (2020). Emotions and decision rightness over five years following an abortion: An examination of decision difficulty and abortion stigma. Social Science & Medicine, 248, 112704. https://doi.org/10.1016/j.socscimed.2019.112704 Roe v. Wade. (n.d.). Center for Reproductive Rights. https://reproductiverights.org/roe-v-wade/ Roncoroni, J., Whitaker, S., Magdamo, B., Hendrix, T., Zaręba, K., & Yohannes, R. (2023). Perceptions of Patient-Centered Care and Their Association With Patient Satisfaction in Abortions for Medical Reasons. Women’s Health Issues, 33(4), 374–381. https://doi.org/10.1016/j.whi.2023.03.001 Ross, L. N. (2022). Childbearing under Unbearable Circumstances: The Importance of Abortion Ban Exceptions for Victims of Sexual Violence and the Current Bias against Sex Trafficking Victims. University of Baltimore Law Review, 52(2), 251–328. Rutherford, F. (2023). FDA Sets Date to Review First US Over-The-Counter Birth Control. Bloomberg.Com, N.PAG-N.PAG. THE DOBBS DECISION 54 Sanger-Katz, M., Miller, C. C., & Katz, J. (2022, July 23). Interstate Abortion Travel Is Already Straining Parts of the System. The New York Times. https://www.nytimes.com/2022/07/23/upshot/abortion-interstate-travel-appointments.html SIECUS. (2023, March 22). Utah State Profile. SIECUS. https://siecus.org/state_profile/utah-state-profile-23/ State Bans on Abortion Throughout Pregnancy. (2023, August 29). Guttmacher Institute. https://www.guttmacher.org/state-policy/explore/state-policies-later-abortions Steupert, M. (2023, August 24). Abortion “Shield Laws”: Pro-Abortion States Seek to Force Abortion on Life-Affirming States. Lozier Institute. https://lozierinstitute.org/abortion-shield-laws-pro-abortion-states-seek-to-force-abortion-on -life-affirming-states/ Thomas, S. P., Kruse, D. E., Houk, J. L., Minkemeyer, V. M., & Jaffe, T. A. (2023). Recruiting and retention of physicians after Dobbs vs. Jackson- the worst is yet to come. Clinical Imaging, 97, 68–69. https://doi.org/10.1016/j.clinimag.2023.02.005 Thompson, K. M. J., Sturrock, H. J. W., Foster, D. G., & Upadhyay, U. D. (2021). Association of Travel Distance to Nearest Abortion Facility With Rates of Abortion. JAMA Network Open, 4(7), e2115530. https://doi.org/10.1001/jamanetworkopen.2021.15530 Traub, A. M., Mermin-Bunnell, K., Pareek, P., Williams, S., Connell, N. B., Kawwass, J. F., & Cwiak, C. (2022). The implications of overturning Roe v. Wade on medical education and future physicians. The Lancet Regional Health – Americas, 14. https://doi.org/10.1016/j.lana.2022.100334 Treder, K. M., Amutah-Onukagha, N., & White, K. O. (2023). Abortion Bans Will Exacerbate Already Severe Racial Inequities in Maternal Mortality. Women’s Health Issues, 33(4), THE DOBBS DECISION 55 328–332. https://doi.org/10.1016/j.whi.2023.04.007 Trost, S., Beauregard, J., Chandra, G., Njie, F., Berry, J., Harvey, A., & Goodman, D. A. (2022, September 26). Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019 | CDC. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html United States Supreme Court, 19-1392 Dobbs v. Jackson Women’s Health Organization (06/24/2022). (2022). Upadhyay, U. D., Weitz, T. A., Jones, R. K., Barar, R. E., & Foster, D. G. (2022). Denial of Abortion Because of Provider Gestational Age Limits in the United States. American Journal of Public Health, 112(9), 1305–1312. https://doi.org/10.2105/ajph.2013.301378 Utah Medical Malpractice Insurance. Utah Medical Malpractice Insurance Overview | Get Free Quote. (n.d.). https://www.gallaghermalpractice.com/state-resources/utah-medical-malpractice-insurance/ Vinekar, K., Karlapudi, A., Nathan, L., Turk, J. K., Rible, R., & Steinauer, J. (2022). Projected Implications of Overturning Roe v Wade on Abortion Training in U.S. Obstetrics and Gynecology Residency Programs. Obstetrics & Gynecology, 140(2), 146. https://doi.org/10.1097/AOG.0000000000004832 What To Do With Frozen Embryos After IVF. (n.d.). Loma Linda University Center for Fertility & IVF. https://lomalindafertility.com/resources/what-to-do-with-frozen-embryos/ Welch, A. (2023, May 2). Breaking: Court Blocks Implementation of Utah Law that Functionally Blocks Abortion | ACLU of Utah. https://www.acluutah.org/en/press/breaking-court-blocks-implementation-utah-law-function ally-bans-abortion THE DOBBS DECISION 56 White, K., Sierra, G., Lerma, K., Beasley, A., Hofler, L. G., Tocce, K., Goyal, V., Ogburn, T., Potter, J. E., & Dickman, S. L. (2022). Association of Texas’ 2021 Ban on Abortion in Early Pregnancy With the Number of Facility-Based Abortions in Texas and Surrounding States. JAMA: Journal of the American Medical Association, 328(20), 2048–2055. https://doi.org/10.1001/jama.2022.20423 Why restricting access to abortion damages women’s health. (2022). PLoS Medicine, 19(7), e1004075. https://doi.org/10.1371/journal.pmed.1004075 Winther, J. F., Boice, J. D., Jr, Svendsen, A. L., Frederiksen, K., & Olsen, J. H. (2009). Induced Abortions in Danish Cancer Survivors: A Population-Based Cohort Study. JNCI: Journal of the National Cancer Institute, 101(9), 687–689. https://doi.org/10.1093/jnci/djp064