Abstract
In 2020, the American College of Obstetricians and Gynecologists published a Committee Opinion with recommendations about improving access to abortion. 1 In that article, they detailed a concerning trend: that abortion care being was being pushed out of mainstream obstetrics and gynecology (OB-GYN) practices and into only specialized centers. In a 2019 national survey of obstetrician/gynecologists, only 24% offered abortion care. 2 This push toward subspecialization in OB-GYN is not unique to abortion; increasing numbers of clinicians are narrowing their scopes of practice across OB-GYN specialties. 3 What is unique about abortion is that it is one of the few topics trainees are allowed to opt out of in residency, which limits the pool of potential providers. 4
There is a growing population of OB-GYN generalists and subspecialists who theoretically support abortion but do not practice it, and who, therefore, have not been affected by the growing number of legislative restrictions on abortion, 5 even prior to the Dobbs v. Jackson Women's Health ruling that eliminated federal abortion protections. 6 Such providers may not consider abortion-related advocacy to be “in their lane,” or may not feel that it is in their professional purview to fight for access to abortion services.
However, in the wake of Dobbs, the tide is changing for abortion advocacy in real time. Dobbs—and its implications—cuts across all areas of gynecology and all areas of medicine. Organizations, including the Society for Maternal–Fetal Medicine, the American Society for Reproductive Medicine, and the Society of Gynecologic Oncology, have all voiced grave concerns about the broad impact that limiting abortion access will have on all aspects of OB-GYN.7–9 For example, abortion care is a necessary aspect of perinatology, a field with many discussions on nonviable pregnancies and maternal mortality. Abortion care is necessary for assisted reproduction wherein creation of healthy pregnancies is the goal, but not all embryos are viable or can be implanted; legislating abortion also runs the risk of hindering in-vitro fertilization access. 9 Abortion care is a vital part of pediatric and adolescent gynecology as sexually active young patients are at high risk of unintended pregnancy, and teen pregnancies carry far higher risk than those in adulthood, particularly in young teens.10,11 Abortion is vital in gynecologic oncology wherein a patient and her clinicians may be faced with a cancer diagnosis in an early pregnancy, having to make decisions about progression of the cancer versus early intervention that risks the pregnancy. 12
The fight for evidence-based abortion care belongs to all of us in OB-GYN. The harm will not be restricted to those clinicians who provide abortion care; the advocacy cannot be restricted either. Dobbs has demonstrated that all of us must join this fight and champion policies that promote abortion care as part of routine OB/GYN care across our fields. Abortion care should be as accessible as a Papanicolaou smear or sexually transmitted infection (STI) testing—not relegated only to specialty clinics and major health care centers.
However, abortion is not the only right that is under attack. Clarence Thomas' concurring opinion in Dobbs stated his goal of having the court reconsider 3 cases that held Roe as precedent: (1) Griswold v. Connecticut (contraception); (2) Lawrence v. Texas (same-sex sexual relationships); and (3) Obergefell v. Hodges (same sex marriage). 13 The need to protect privacy, and its implications, squarely puts legislative advocacy in the lane of every obstetrician/gynecologist committed to evidence-based medicine and to providing ethical, necessary patient care. An obstetrician/gynecologist who cannot prescribe contraception or who cannot counsel about sexual activity without risking their patients' freedom, is an obstetrician/gynecologist who cannot do the required job.
Just as with abortion, the risk to contraceptive access will not just be felt in family planning counseling, as contraception is not just about preventing pregnancy. Minimally invasive gynecologic surgeons use contraception to manage leiomyomas. 14 Gynecologic oncologists use levonorgestrel intrauterine devices to manage endometrial intraepithelial hyperplasia. 15 Legislation is already encroaching on medical standards or care; early reports suggest that some patients with lupus can no longer access methotrexate because of its potential use as an abortifacient. 16
Lawrence v. Texas decriminalized sodomy and paved the way for patients and their partners to engage in open and honest conversations with their clinicians about sexual activity. A growing body of data has reinforced that creating safe clinical spaces for open and honest conversations about sexual activity improves STI screening and prevention practices as well as sexual and reproductive-health outcomes.17,18 This is not just true for sexual and gender minority patients but also heterosexual, cisgender patients who engage in unprotected anal sex and other activities for which they may need specific screening. 19 Protecting sexual liberty is critical to providing high-quality care for all patients.
While the legalization of relationships may seem unrelated to OB-GYN practice, Obergefell v. Hodges too has direct links to patients' outcomes. The right for non-heterosexual couples to marry improves mental health and reduces socioeconomic disparities; both aspects are linked to positive sexual and reproductive-health outcomes. 20 Legal unions are also often used to gatekeep access into clinical spaces; pre-Obergefell horror stories remind us that loved ones were prevented from being present alongside patients in their times of need. 21 Perinatologists and obstetricians will face even greater hurdles in ensuring the parental rights of LGBTQ+ patients and their spouses.
The siloed nature of abortion care led to its limited availability, even before Dobbs, even though the need for abortion care cuts across all of OB-GYN. What will be next? Obstetrician/gynecologists have a choice: We can focus on our narrow clinical scopes, hope these legal challenges do not come to fruition, and wait to assess the inevitable compromises to patient care if and when they do occur. Alternatively, we can be proactive and start working now to protect our patients and our field.
Whose voices will shape the field of OB-GYN today, next week, and next year? Will it be doctors and nurses or legislators and jurists? One in 4 women who can get pregnant will have an abortion in her lifetime. 1 A far greater number will use contraception, engage in non-penile–vaginal sexual activity, and/or desire a non-heterosexual marriage. Will they receive evidence-based medicine or ideologically driven care? This fight does not belong to only abortion providers. It is the struggle of our entire profession.