Abstract
This survey study compares the proportion of abortion-providing clinicians who changed primary state of practice after the Dobbs v Jackson Women’s Health Organization decision in 2022.
Introduction
Intensifying state-level abortion restrictions following the Dobbs v Jackson Women’s Health Organization (2022) decision could lead clinicians to leave states that ban abortion.1 While large-scale changes are not yet apparent among obstetrician-gynecologists, the abortion care workforce may be uniquely at risk.2 We examined the proportion of abortion-providing clinicians who changed primary state of practice, comparing those who left states that banned abortion with those who left states that did not ban abortion after Dobbs, and the ban status of the states to which they relocated.
Methods
This survey study was approved by The Ohio State University institutional review board. From May to December 2023, we disseminated an electronic, purposive survey to national professional listservs for abortion-providing clinicians and through snowball sampling.3 Following AAPOR reporting guidelines, we recruited clinicians (physicians, advanced practice clinicians, and nurses) who provided abortion the year before Dobbs and/or at the time of the survey.4 Surveys queried primary practice state in the year before Dobbs and at the time of the survey. Electronic informed consent was obtained prior to the survey.
We categorized states based on abortion policy. Any state with a near-total abortion ban or 6-week gestational abortion ban in effect at any time following Dobbs (June 2022) and our survey’s close (December 2023) was categorized as a ban state. All other states were categorized as no-ban. If clinicians reported a different primary practice state in the year before Dobbs compared with their primary practice state during the survey, they were categorized as relocating primary practice state.
Finally, we assessed the proportion of clinicians who changed primary practice state from a ban state to a no-ban state. Analyses were conducted in Stata version 18 (StataCorp) in November 2024. The threshold for statistical significance was a 2-sided P < .05.
Results
Of 388 respondents, 346 (89%) met eligibility and consented. We excluded respondents not practicing before Dobbs (19 respondents) or not reporting primary practice state before and after Dobbs, for an analytic sample of 305 (79%). Most respondents (277 respondents [91%]) reported providing some nonabortion health care (Table 1). Respondents reported primarily practicing in 44 states and Washington DC, with 227 respondents (74%) practicing in no-ban states and 78 (26%) practicing in ban states before Dobbs (Table 1).
Table 1. Characteristics of Clinicians Providing Abortion Before Dobbs v Jackson Women’s Health Organization .
| Characteristic | Clinicians, No. (%) (N = 305) |
|---|---|
| State of primary practicea | |
| No-ban state | 227 (74) |
| Ban state | 78 (26) |
| Region of primary practice | |
| West | 61 (20) |
| Southwest | 29 (10) |
| Midwest | 63 (21) |
| Southeast | 77 (25) |
| Northeast | 75 (25) |
| Clinical care | |
| Provided some nonabortion care | 277 (91) |
| Only provided abortion care | 28 (9) |
| Healthcare role | |
| Obstetrics and gynecology | 166 (54) |
| Family medicine | 55 (18) |
| Other physician | 5 (2) |
| Advanced practice clinician, nurse practitioner | 41 (13) |
| Advanced practice clinician, physician assistant | 6 (2) |
| Advanced practice clinician, certified nurse midwife | 12 (4) |
| Advanced practice clinician, other | 2 (1) |
| Nurse | 18 (6) |
| Complex Family Planning Fellowship (physicians only), No./total No. (%) | |
| Yes (completed or currently completing) | 120/226 (53) |
| No | 106/226 (47) |
| In training | |
| Yes | 26 (9) |
| No | 279 (91) |
| Primary practice setting | |
| Community hospital | 12 (4) |
| Academic hospital | 85 (28) |
| State-funded institution | 4 (1) |
| Planned Parenthood | 115 (38) |
| Independent clinic | 73 (24) |
| Telehealth | 8 (3) |
| Other | 6 (2) |
| Missing | 2 (1) |
Ban or 6-week ban was coded based on the implementation of a near total ban or a 6-week gestational ban on abortion between June 2022 (Dobbs) and December 2023 (the end of our survey). These states include Alabama, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, West Virginia, and Wisconsin.
Overall, 47 respondents (16%) relocated primary practice state. Clinicians practicing before Dobbs in states that would ban abortion were much more likely to relocate primary practice state than those in no-ban states (27 respondents [42%] vs 20 respondents [9%]; P < .001) (Table 2).
Table 2. Changes in Practice After Dobbs v Jackson Women’s Health Organization .
| Characteristic | Clinicians by pre-Dobbs primary state of practice, No./total No. (%) | P value | ||
|---|---|---|---|---|
| Total | No ban | Ban or 6-wk bana | ||
| Abortion provision | ||||
| Not currently providing | 17/305 (6) | 4/227 (2) | 13/78 (17) | <.001 |
| Currently providing (post-Dobbs) | 288/305 (94) | 223/227 (98) | 65/78 (83) | |
| Moved primary practice state | ||||
| Did not move | 241/288 (84) | 203/227 (91) | 38/78 (58) | <.001 |
| Moved | 47/288 (16) | 20/227 (9) | 27/78 (42) | |
| Move typea | ||||
| Ban to ban | 3/47 (6) | NA | 3/27 (11) | NA |
| No-ban to ban | 2/47 (4) | 2/20 (10) | NA | |
| Ban to no-ban | 24/47 (51) | NA | 24/27 (89) | |
| No-ban to no-ban | 18/47 (38) | 18/20 (90) | NA | |
Ban or 6-week ban was coded based on the implementation of a near total ban or a 6-week gestational ban on abortion between June 2022 (Dobbs) and December 2023 (the end of our survey). These states include Alabama, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, West Virginia, and Wisconsin.
Of those who relocated from ban states, most (24 of 27 respondents [89%]) relocated to no-ban states. Among those who relocated from no-ban states, most relocated to another no-ban state (18 of 20 respondents [90%]) (Table 2). Some respondents (17 of 305 respondents [6%]) stopped providing any abortion care after Dobbs, mostly in ban states (13 respondents total) (Table 2).
Discussion
This survey study found that after Dobbs, 42% of survey respondents who provided abortions in states banning abortion relocated to another state. Almost all clinicians who relocated from any policy context relocated to states not banning abortion. We document practice relocation rates vastly exceeding those of obstetrician-gynecologists from 2005 to 2015, and among obstetrician-gynecologists post-Dobbs.2,5 Broader reproductive health care workforce patterns can take years to develop. Our findings among clinicians providing abortion give early insights into future workforce shifts. Given that most study respondents provided both abortion and nonabortion health care, these accelerated relocations have implications for abortion access and for the broader maternal health workforce, exacerbating health care deserts and outcome disparities.6
This study has limitations. Our sample is purposive because listservs used for recruitment protect member identities and numbers and our study may have selection bias. These privacy measures are necessary for study participant protection given the sensitive nature of abortion provision.4 Our study reflects abortion-providing clinicians, not the broader reproductive and maternal health care workforce.
When clinicians cannot provide the standard of care, they may leave. Patients left behind could lack access to reproductive and maternal health care.
Data Sharing Statement
References
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Associated Data
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Supplementary Materials
Data Sharing Statement
