Tag: Abortion

Destination Unknown: Navigating Abortion Training in Post-Dobbs America

Abortion is not only common but an essential component of comprehensive care, with one in four pregnant people accessing abortion care in the United States. During my annual physical this summer, I reflected on what challenges people seeking abortion care in my home state of Georgia – and across the Southeast – now face. As the conversation drifted from lab results to my research in reproductive rights law, my doctor posed a question I hadn’t considered: What happens if the next generation of physicians is denied the right to train in abortion care?

On June 24, 2022, the Supreme Court’s decision in Dobbs v. Jackson Women’s Health signaled a seismic shift in reproductive care, affecting not only patients, but physicians in training. The fight to preserve abortion care has moved far beyond the operating room, and now extends to fellowship and residency programs, where trainees do not know if they will ever receive abortion care experience. In a nation where abortion is no longer a constitutional right, medical students, residents, and fellows in states with restrictive abortion laws are being forced to seek training across state lines, and even abroad. One fourth-year medical student planning to pursue a specialty involving family planning, was forced to independently find a rotation that would provide abortion care training, and had to travel as far as London after her school’s reproductive health clinic shut down. 

Training in abortion care for medical students and resident physicians already had significant limitations pre-Dobbs in states with restrictive abortion laws. Along with barriers associated with geographic location or having the resources to travel, patients must now face the additional challenge of finding a physician with enough training to provide an abortion.

Critics of widespread access to abortion care often argue that medical exception laws are enough to prevent maternal mortality or morbidity. However, these “exceptions,” often written into law by people without medical training, using nonmedical language, have resulted in mass confusion for clinicians who, when faced with split-second decisions, are forced to deny or delay care for their patients. Post-Dobbs, there is scant opportunity for doctors in training to have hands-on abortion care experience in states that operate on medical exception laws.

Within Family Medicine and Obstetrics and Gynecology, some family planning program directors have already expressed concerns about the ability to attract residents and fellows to programs in states with abortion bans. These concerns are not without basis, with a cross-sectional study of 2,436 OB-GYN residency programs revealing a small but significant decrease in the number of applicants to residency programs in states with strict abortion laws. According to the study, state-specific abortion restrictions are impacting the training of around 44% of OB-Gyn residents in the U.S. Even though OB-GYN residency programs were also completely full in 2023, there was a statistically significant decrease in applications compared to 2022, and years pre-Dobbs.

While the long-term on the OB-GYN workforce may not be visible just yet three years out from the Dobbs decision, should the trend continue, maternal mortality and morbidity may rise, especially in maternal care deserts. Maternal care deserts are defined as counties where hospitals lack obstetric services, birth centers, obstetricians, gynecologists, or certified nurse-midwives. Maternal care deserts are often found in rural areas, with most rural countries having maternal mortality rates close to two times higher than rates in urban counties.

The future of abortion care training in OB-Gyn and Family Medicine residency programs in states with restrictions is uncertain, with no clear path forward. While some states with restrictive laws may offer medical exceptions, these may not provide enough opportunities for medical students and residents to gain enough training to confidently perform these procedures, impacting the standard of care nationwide.

EMTALA in the Age of Rising Abortion Bans

Following the decision in Dobbs v. Jackson Women’s Health Organization in 2022, abortion bans have been popping up in states across the country. Many states have qualified their bans with exceptions based on the gestational age of the pregnancy, assault, or medical necessity. However, for 12 states, the exceptions, if present at all, are narrow, creating near-total abortion bans. This has widespread implications not just for patients, but for medical providers who traditionally provide abortions or greater obstetrics care.

One specific class of providers has found itself in the middle of a clash between state and federal law due to these bans. Emergency medical providers are not just bound by state law, but by the Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA is a federal act passed in 1986 as a response to a problematic practice of “patient dumping,” where hospitals refuse to treat low-income patients or patients from marginalized communities and transfer them to other hospitals. The primary requirement of the act is that any patient who arrives at an emergency room in a hospital that receives Medicare funding must be screened and stabilized before being transferred or released. The majority of guidance on EMTALA has left the medical decision-making aspect of stabilization and treatment up to the discretion of medical providers within the scope of their capabilities and the current standards of care.

The issue arises in cases where an abortion is determined to be medically necessary for the stabilization of a patient by a provider in an emergency setting. Pregnancy complications are the fifth most common reason that women between 18 and 65 visit the emergency room, with 84% of women visiting the emergency room at some point during their pregnancy. Due to the breadth of procedures that fall under the clinical term “abortion,” many medical procedures required for emergency obstetrics care fall under the abortion umbrella. Often, these procedures are life-saving and needed for even the most basic stabilization of a pregnant patient, such as in the case of ectopic pregnancy.

A few cases reflecting this conflict have made their way to the Supreme Court, hoping to receive a concrete answer as to whether emergency abortion procedures would remain protected. The most recent of these is Idaho v. United States, where the DOJ contended that Idaho’s near-total abortion ban would have to yield to federal law in terms of the provision of necessary stabilizing treatment. However, SCOTUS dismissed the complaint in 2024 without a specific ruling on the interaction between EMTALA and abortion bans, finding that the writ of certiorari was improvidently granted.

Despite this dismissal, the Supreme Court has another chance to hear arguments concerning the interaction between EMTALA and abortion bans due to a recent lawsuit where Texas sued the DOJ in an attempt to force ER compliance with the state’s strict abortion ban. The Fifth Circuit Court of Appeals sided with the state, allowing for the abortion ban to prevail over EMTALA obligations. The DOJ, under President Biden, filed for a review of the decision in 2024, but after the change in administration, it remains to be seen whether the DOJ will continue to pursue the complaint or whether SCOTUS will hear the case.

Without a clear ruling from federal courts, the conflict between the duties of providers under EMTALA and state-based bans leaves providers wary of legal repercussions, no matter which actions they take. Guidance from the Center for Medicare & Medicaid Services, as given in 2022, stated that providers would be protected under EMTALA for the provision of medically necessary abortions for the stabilization of emergent patients. However, that guidance was rescinded under President Trump as of June 3rd, 2025, and subsequent communication from the HHS on June 13th, 2025, was unclear. The lack of clear information and rising legal consequences of providing abortions in certain states have thrust providers and patients alike back into a state of uncertainty and fear.

The Future of Abortion Pill Mifepristone Now Uncertain as it Faces a New Missouri District Judge

The US District Court for the Eastern District of Missouri is the new battleground for the legal fight over access to the abortion pill Mifepristone. This development comes after the Supreme Court remanded Judge Matthew Kacsmaryk’s injunction against the FDA’s current regulations on the drug last summer, ruling the case had no legal standing in Texas. Given the options to dismiss the case or transfer it to another venue, Judge Kacsmaryk announced his decision to transfer the case to the Eastern District of Missouri.

The Attorney Generals for Missouri, Idaho, and Kansas joined the plaintiff, the Alliance for Hippocratic Medicine, last October to challenge the FDA’s restrictions on Mifepristone.

Their arguments challenging the FDA’s 2000 approval of Mifepristone center around claims that the drug is unsafe, citing statistics that 3-5% of women who take Mifepristone end up hospitalized due to complications from the medication. The plaintiffs are advocating for the reinstatement of previous regulations surrounding the drug, including rolling back the Mifepristone REMS program, which allows the medication to be dispensed by mail. Additionally, they’re requesting that the FDA implement new regulations requiring three in-person doctor visits before access to Mifepristone is granted. Given that medical abortions made up 63% of all abortions in 2023, restricting access to this abortion medication would have a significant impact nationwide.

This latest development leads to new apprehensions for reproductive health advocates. One such concern is how the new Missouri venue may grant the plaintiff, specifically the Attorney General of Missouri, an advantage in the forthcoming litigation.  The pool of judges is also a worry in reproductive rights groups. Among Missouri district judges who could hear this case are Zachary Blueston and Christian Stevens, who were both nominated to the court by the Trump Administration. Other potential judges include Joshua Divine and Maria Lanahan, two more Trump nominations who both represented Missouri in prior Mifepristone litigation earlier this year. The Trump Administration has been public about its pro-life views and has already taken steps to cut access to abortion. More recently, the Administration expressed skepticism about Mifepristone. These findings suggest that the judges who may potentially preside over the Mifepristone case already have anti-abortion biases that reproductive health advocates are worried will reflect in the court’s ultimate decision.

The Eastern District of Missouri has not publicly announced whether it will accept the case, nor given any statement about who the presiding judge might be. Now that this case has gone up and back down from the Supreme Court, Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration is up for a second round of litigation. It is to be seen if the battle will reach its climax in Eastern Missouri’s District Court.