Abortion access and the US medical workforce: a looming crisis for hematology

The June 24, 2022 Dobbs versus Jackson decision by the United States (US) Supreme Court has many grave implications; among them is that bans or severe limitations on therapeutic abortion will negatively affect the US physician workforce, including the hematology workforce.¹ When physicians cannot obtain needed, evidence-based healthcare, the proverb Physician, heal thyself becomes an impossibility, compromising physicians’ ability to provide compassionate and comprehensive patient care.

At least 25-30% of practicing hematologist-oncologists in the US identify as female, and with improved gender parity in US medical trainees, this percentage will likely increase over time.² Because 80-90% of practicing hematologist-oncologists report having children,³ child-bearing and reproductive planning is pertinent to a large and growing portion of the workforce.

The risks of childbirth and its aftermath are substantial for physicians. Physicians who become pregnant have a higher mean age at first pregnancy compared with other working professionals, are more likely to have infertility evaluation and use assisted reproductive technologies (ART), and have higher rates of pregnancy complications than the general population.⁴ Mothers who are physicians report high rates of postpartum depression, and the majority also endorse stigmatizing beliefs about physicians suffering from mental illness, leading to lack of appropriate treatment.⁵ Many institutions offer physicians who deliver babies less paid maternity leave than recommended. Many do not offer any paid leave for parents who have not physically given birth including those who build families via adoption or gestational carrier.⁶ Lactation/breastfeeding provisions at many institutions are woefully inadequate.

Even after surviving childbirth and the immediate post-partum period, physician mothers also face multiple career and work-life integration challenges. Most US physician mothers are partnered or married, and also report having primary responsibility for domestic tasks, including childcare.⁷ Physician mothers experience job discrimination, negative bias affecting consideration for promotion, workplace disrespect, and unequal pay.⁸ Parenthood might contribute to the inequalities in career advancement, worse work-life integration, and higher risk of workforce attrition among female physicians compared with their male counterparts.⁹

The human right to reproductive autonomy protects the right to pursue pregnancy or not. Many physicians choose childbirth and child raising with awareness of the potential challenges to physical well-being and career. However, the choice not to pursue pregnancy is equally fundamental. Abortion bans force some women to continue unwanted and/or life-threatening pregnancies. Forcing anyone to proceed with pregnancy when the personally appraised risks outweigh the benefits is a human rights violation.

Abortion access is essential for the US physician workforce. More than 11% of physicians who have been pregnant report having at least one therapeutic abortion. Physicians living in states that have regressed to tightly restricting abortion—or have banned abortion outright— are at risk for severely, unjustly compromised reproductive choices. We can expect this will impact physicians’ ability to work. Pregnant physicians seeking abortion care might need weeks of advanced notice to adjust their call schedules to travel out of state for abortion care or face excessively long waiting times in their state of residence. They also have a higher average age at first pregnancy and therefore face higher risk of fetal chromosomal abnormalities, which are often confirmed after the first trimester. For these reasons, physicians require access to second-trimester abortion care. Abortion is expensive when paid for out of pocket and, as of 2021, only seven states in the USA required private insurance agencies to cover abortion care. This is in stark contrast to the healthcare policies in many other high-income countries, where access to abortion is decriminalized, more universally available until later in pregnancy, and often publicly funded.¹⁰

The Dobbs decision also ART, which includes in-vitro fertilisation and any other fertility-related treatments in which eggs or embryos are manipulated. As up to one in four female physicians experience infertility (twice the rate of the general population)¹¹, restrictions to ART could further compromise the US physician workforce. ART poses extreme physical, emotional, and financial toll and requires a substantial time commitment.¹² In a post Dobbs USA, physicians living in states without abortion access must now also worry about whether their care will be derailed by the contested idea of fetal personhood (considering embryos to be people) obstructing the choice to use or discard stored embryos. Knowledge of these increasingly overwhelming obstacles might dissuade people from undergoing egg or embryo cryopreservation to preserve fertility during medical training or dissuade them from using ART to address infertility later in their medical careers. As awareness of infertility risks affecting women physicians is increasing through counselling of medical and pre-medical students, those who can become pregnant might become dissuaded to pursue careers in medicine due to increasing family-building barriers.

Adoption is often cited as additional way to build a family or as an alternative to abortion in the setting of unwanted pregnancy. However, like other methods of family-building, pursuing adoption is not procedurally simple, nor is continuing a pregnancy with the intention of placing a baby for adoption, which might also be life-threatening to the mother. For potential parents the adoption process can be daunting in terms of time and expense, and adoptive parents might not be granted the same rights to parental leave as those who build families by biological methods. For those who are pregnant and do not wish to become parents, carrying a pregnancy to term for the purpose of adoption requires assuming the same increased risk of pregnancy-related health complications as well as navigating the complex personal and social dimensions of making this choice.

Efforts to increase the recruitment and retention of women in hematology are also jeopardized by abortion restrictions. Medical training is lengthy, and many physicians choose not to have children during training or early in their careers while building a sustainable career that allows for full participation in the workplace. For people with a womb, forced pregnancy might deter the undergraduate student from pursuing medical school, the medical student from pursuing certain residencies, the resident from pursuing subspecialty training, and the early-career physician from continuing a career in medicine altogether. Further, abortion restrictions are anticipated to disproportionately affect communities of color.¹³ Among the implications of this potentially dismal outcome is that health-care professionals who identify with these under-represented groups are more likely to provide care for patient populations whose needs are already inadequately met, extending the impact of Dobbs from physician to patient.¹⁴

The loss of reproductive autonomy in many US states might impact the recruitment and retention of trainees and practicing hematologists to areas affected by abortion ban. Classical haematology might be the field most adversely affected by a worsening workforce shortage, as one study suggests that recruitment and retention to adult classical haematology is already substantially limited by a perception of poorer income potential, research funding, job availability, and job security than oncology. This study, published before the recent Supreme Court ruling, did not investigate the association between access to reproductive health care and career choices during and after fellowship training. The growing costs and barriers to reproductive healthcare needs ranging from abortion to infertility treatment will not improve prospects for recruiting sorely needed classical hematologists to the field. Abortion restrictions will have negative effects on already limited patient care if we are unable to recruit future hematologist to practice in areas where abortion care is limited or unavailable. Further studies of the effect of abortion bans on the regional recruitment and retention of US hematologists, with a focus on women and under-represented minorities, are needed.

US professional societies such as the American College of Obstetricians and Gynecologists and the American Society of Reproductive Medicine have stated their intentions to defend reproductive autonomy in the USA. Expecting only specialists directly involved in providing abortion care to defend reproductive autonomy alone is unrealistic and unfair; abortion bans affect all of our patients, our colleagues, our trainees and their families. Hematologists and their professional societies should help lead the larger medical community by insisting that abortion is health care and that the personal decisions made between a patient and a physician should never be subject to government intrusion.

Our field has made substantial efforts to improve gender equity in the workforce and now is the time to ensure that those efforts are not reversed. A large portion of the current and future hematology workforce has the potential to become pregnant. Parenthood by choice already places unequal health and career burdens on female hematologists. Parenthood by lack of choice will magnify these inequalities and exacerbate barriers to entering the field, mental health challenges, poorer work-life integration, slower career advancement, and, ultimately, workforce attrition. For a field already facing substantial workforce shortages, this is an outcome we cannot afford. For a field that prides itself on compassion and justice, this is an outcome that is morally unacceptable.