Abortion Bans and Pregnancy-Related Care Across Physician Specialties

Key Points

Question

How are state-level total abortion bans associated with abortion-adjacent clinical care and patient outcomes across medical specialties?

Findings

In this qualitative study of 40 US physicians practicing in 9 states with total abortion bans, participants reported delays in care and deviations from standard practice across a range of abortion-adjacent conditions, ambiguity and fear among physicians, loss of patient autonomy and shared decision-making, erosion of trust between patients and physicians, physicians being placed into a gatekeeping role, and increased health system burdens driven by legal risk rather than clinical need.

Meaning

These findings suggest that abortion bans have broad downstream consequences on medical care beyond abortion itself, shifting clinical decision-making away from patient-centered care and professional judgment toward legal risk mitigation, with implications for patient safety, equity, and physician ethics.

This qualitative study examines the association of abortion restrictions with abortion-adjacent care across medical specialties via interviews with US physicians who care for pregnant patients.

Abstract

Importance

Following the Dobbs v Jackson Women’s Health Organization decision, states with abortion bans have experienced increased maternal morbidity and mortality. However, the associations of these restrictions with abortion-adjacent care—medical care directly affected by or overlapping with abortion, such as management of early pregnancy loss (EPL), ectopic pregnancy, and other pregnancy complications—are not well described.

Objective

To examine how state-level abortion bans are associated with abortion-adjacent clinical care among physicians from different medical specialties.

Design, Setting, and Participants

This qualitative study was conducted between May 13, 2024, and May 23, 2025, using purposive and snowball sampling. Participants included physicians from emergency medicine, family medicine, and obstetrics and gynecology specialties practicing in 9 states with total abortion bans. Semistructured interviews were conducted via videoconference and analyzed using an inductive thematic approach with dual independent coding.

Exposure

Medical practice in a state with an abortion ban.

Main Outcomes and Measures

Participant-reported experiences with clinical decision-making, care delivery, counseling practices, and professional responsibilities in the context of abortion bans.

Results

A total of 40 physicians (18 in obstetrics and gynecology, 8 in family medicine, and 14 in emergency medicine) across 9 states participated, 30 (75.0%) of whom were female. Mean (SD) length of time in practice was 7.9 (6.1) years. Six major themes emerged: (1) delays in care and deviations from standard practice for EPL, ectopic pregnancy, molar pregnancy, preterm prelabor rupture of membranes, and maternal comorbidities; (2) ambiguity and fear among physicians; (3) loss of patient autonomy and shared decision-making; (4) erosion of trust in the patient-physician relationship; (5) placement of physicians into new gatekeeping roles; and (6) increased health care system burdens. Physicians described requiring additional confirmatory testing, seeking institutional approval even for emergent life-saving interventions, and being forced to determine which patients were sick enough to receive medically indicated care.

Conclusions and Relevance

In this qualitative study of the consequences of abortion bans across multiple medical specialties, abortion bans were associated with disrupted clinical care far beyond what is traditionally categorized as abortion, with treatment delays that endanger patients, undermined patient autonomy and physician-patient trust, and with new gatekeeping roles for physicians. These restrictions shifted medical decision-making from clinical judgment and patient values toward legal risk mitigation, with potential long-term consequences including exacerbation of health care inequities and compromised ability to provide safe and effective care for pregnant patients.

Introduction

Since the Dobbs v Jackson Women’s Health Organization decision overturned Roe v Wade, the constitutional right to abortion has been eliminated, enabling state legislatures to severely restrict or ban abortion. As of January 2026, 13 states have total abortion bans, and 41 others impose gestational limits, including 7 that prohibit abortion at or before 18 weeks’ gestation.^1,2 Loss of abortion access carries significant risk, as morbidity and mortality of pregnancy and childbirth exceed those of abortion.^3,4 Analyses of Centers for Disease Control and Prevention data show that pregnant individuals in states with abortion bans are nearly twice as likely to die during pregnancy, childbirth, or the postpartum period compared with those in states without such restrictions.⁵ Black pregnant people in these states face more than 3 times the risk of death compared with their White counterparts, underscoring the exacerbation of longstanding inequities in maternal health.⁵ Denial of wanted abortion is also associated with long-term social and economic consequences, including increased poverty, housing and food insecurity, ongoing exposure to intimate partner violence, and lower life satisfaction and self-esteem.^6,7,8

Emerging evidence suggests that abortion bans also disrupt abortion-adjacent care—medical care that is directly affected by or that overlaps with abortion care, such as management of early pregnancy complications. While many of these interventions, such as management of early pregnancy loss (EPL) or ectopic pregnancy, may meet clinical definitions of abortion, they are not consistently conceptualized or described as such by clinicians. This care occurs across emergency, primary care, and obstetrical settings that comprise the reproductive health safety net. Early post-Dobbs data indicate significant treatment delays, constraints on clinicians’ ability to counsel and follow evidence-based practice, and profound practical and emotional tolls on patients.^{9,10,11,12,13,14,15} The goal of the present study was to examine the association of abortion restrictions with abortion-adjacent care across specialties through qualitative interviews with physicians who care for pregnant patients.

Methods

Study Design and Participants

We conducted a qualitative study with a cross-sectional design to examine the experiences of physicians caring for pregnant patients under state-level abortion bans. The analysis focused on the association of these bans with clinical care and is part of a broader investigation of physician experiences. The study design was informed by an interpretivist paradigm to capture perspectives on how bans shape clinical decision-making and care. The study was approved by the Beth Israel Deaconess Medical Center Institutional Review Board, and all participants provided verbal informed consent. We followed the Standards for Reporting Qualitative Research (SRQR) reporting guideline.

Eligible participants included emergency medicine (EM), family medicine (FM), and obstetrics and gynecology (OB-GYN) physicians who practiced in states with total abortion bans and cared for pregnant patients. Participants were recruited using purposive and snowball sampling to capture a range of perspectives across clinical specialties and geographic regions. Professional contacts at institutions in affected states were invited to participate via email and to share study information with colleagues. Race and ethnicity were self-reported and were categorized as Asian, Black, Latinx, White, multiracial, and not disclosed; these data were collected to characterize the study sample and assess the diversity of perspectives represented, since participants’ racial and/or ethnic background are part of their identities that may influence their relationship to their work or patient populations impacted by health policy.

A semistructured interview guide was used to explore physicians’ experiences caring for pregnant patients under abortion bans, including clinical decision-making, management of pregnancy-related conditions, counseling practices, perceived legal constraints, and professional responsibilities and patient care. The guide included open-ended questions with targeted probes to elicit detailed clinical scenarios and experiences. The interview guide is provided in the eAppendix in Supplement 1.

Researcher Characteristics and Reflexivity

The study team included clinicians and researchers with expertise in reproductive and public health in different states with various reproductive rights and legislative climates. Interviewers were trained in qualitative methods and reflected on how their experiences might influence data collection and interpretation.

Data Collection

Interviews were conducted between May 13, 2024, and May 23, 2025, via videoconference by trained team members (S.L., E.N.H., and S.N.). The semistructured interview guide was used to explore clinical decision-making, patient care, counseling practices, and the influences of abortion bans on physicians’ professional responsibilities. Interviews lasted 30 to 45 minutes and were audiorecorded with participants’ consent. Recordings were transcribed verbatim, reviewed for accuracy, and deidentified. Data collection and analysis occurred concurrently and continued until thematic saturation was reached.

Data Analysis

Data were analyzed using an inductive thematic approach. Two independent coders reviewed and coded transcripts using Delve software (Delve Technologies Inc). Discrepancies were resolved through discussion to achieve consensus. Codes were iteratively organized into broader categories and refined into themes first by the 2 coding authors (S.L. and E.N.H.), then subsequently by the study team to reach consensus on analytic themes. Thematic saturation was considered reached when no new themes emerged across successive transcripts. Representative quotations were selected to illustrate themes and preserve participants’ voices.

Results

We conducted 40 semistructured interviews with physicians practicing in OB-GYN (n = 18), FM (n = 8), and EM (n = 14) (Table 1). Mean (SD) length of time in practice was 7.9 (6.1) years; 30 participants (75.0%) were female and 10 (25.0%) were male. Most were attending physicians (36 [90.0%]) and practiced in an academic setting (29 [72.5%]). In terms of race and ethnicity, 4 participants (10.0%) were Asian, 1 (2.5%) was Black, 1 (2.5%) was Latinx, 31 (77.5%) were White, 2 (5.0%) were multiracial, and 1 (2.5%) did not disclose their race or ethnicity. Participants represented 9 states with total abortion bans (Alabama, Idaho, Indiana, Kentucky, Mississippi, Oklahoma, Tennessee, Texas, and West Virginia) (Figure), and most practiced in the South (31 [77.5%]) (Table 1).

Table 1. Participant Characteristics.

Characteristic	No. (%) of participants (N = 40)
Sex
Female	30 (75.0)
Male	10 (25.0)
Race or ethnicity
Asian	4 (10.0)
Black	1 (2.5)
Latinx	1 (2.5)
White	31 (77.5)
Multiracial	2 (5.0)
Not disclosed	1 (2.5)
Medical specialty
Obstetrics and gynecology	18 (45.0)
Emergency medicine	14 (35.0)
Family medicine	8 (20.0)
US region
South	31 (77.5)
West	6 (15.0)
Midwest	3 (7.5)
Practice settinga
Academic hospital	29 (72.5)
Community hospital	18 (45.0)
Federally qualified health center	3 (7.5)
Private practice	2 (5.0)
Time practicing in state, y
<5	14 (35.0)
5-9	12 (30.0)
10-14	9 (22.5)
15-19	2 (5.0)
≥20	3 (7.5)
Level of training
Attending physician	36 (90.0)
Trainee (fellow or resident)	4 (10.0)

^a Participants could select more than 1 practice setting.

Figure. Map of States With and Without Abortion Bans.

Stars indicate states represented in the present study: Alabama, Idaho, Indiana, Kentucky, Mississippi, Oklahoma, Tennessee, Texas, and West Virginia.

Physicians described challenges across a range of clinical scenarios, including EPL, ectopic pregnancy and pregnancy of unknown location (PUL), molar pregnancy, preterm prelabor rupture of membranes (PPROM), and pregnancies complicated by maternal comorbidities. Themes were generated inductively across these discussions and reflect shared patterns in physician experiences across clinical contexts.

Delays and Deviations From Standard Practice

Across clinical scenarios, physicians reported delays in treatment driven by legal uncertainty and the need for diagnostic confirmation prior to intervention. In EPL, abortion bans compelled additional, sometimes unnecessary, confirmatory testing to demonstrate that a pregnancy was nonviable. This often required multiple ultrasonograms or serial measurements of β–human chorionic gonadotropin levels, even when clinical assessment was consistent with EPL. Physicians described delaying intervention despite clinical findings highly suggestive of EPL (Table 2).

Table 2. Themes and Sample Quotes.

Theme	Sample quotes	Specialty
Delays and deviations from standard practice	Certain cases in [state] where patients happen to be pregnant, but also septic. And just because you’re so unbelievably afraid to cause a miscarriage with antibiotics or medications or treatment, it’ll just be like, “you’re pregnant—hands off.”	EM
	We’re waiting longer and putting people at more risk because we … feel pressured to have an absolute definitive diagnosis before treating.	FM
	There was a patient with bleeding … the crown rump length was like … 5 mm, and there was no FH, but it’s not 7 mm so you can’t diagnose EPL … I had to say, “We can’t do the D&C right now … You have to come back in a week.”	OB-GYN
	There was a patient who had a very high-risk C-section scar ectopic…. To help with reduction of blood loss in a uterine-sparing procedure, I really needed help from my interventional radiology colleagues for uterine artery embolization, and they were just not willing. This patient had heart tones, and ultimately the patient continued her pregnancy, had a very complicated placenta accreta case, and is alive, but had a very complicated course, ended up obviously losing her uterus.	OB-GYN
	We had … a 21-week patient with severe cardiomyopathy…. She came in at 21 weeks, ejection fraction of like 10%, and was on pressors. And so we were like … the baby needs to be delivered. This is not safe for her … she’s about to die. And so we … consulted legal and we wrote a letter and cardiology wrote a letter and then we did her cesarean.	OB-GYN
Ambiguity and fear among providers	What happens when somebody shows up to the ER and they’re 26 weeks and bleeding heavily? I think a lot of people haven’t figured out … how are we gonna handle these kind of situations? What if there’s cardiac activity? What does that mean?	FM
	I’ve heard that some folks are even concerned about the management of known ectopic pregnancies … that confusion still ends up impacting how patients receive care.	FM
	A patient … had what looked like a partial molar pregnancy. I said, “I think that this is a molar pregnancy. The law says that I can intervene. But what happens if I do a D&C and the pathologist doesn’t see molar pregnancy tissue?” … You’d think it would be really easy to make those decisions, but … there’s a way for me to guess and be wrong. And even though it feels wrong to make the patient wait, ultimately we watched her … then the pregnancy luckily demised and we did a D&C … but that felt like a significant delay in care.”	OB-GYN
	My diagnosis is highly suspicious for molar pregnancy. I’m going to proceed with the D&C. But I went into that surgery that day wondering if I was going to be in jail in a couple of months for doing it.	OB-GYN
Gatekeeping and shift in decision-making authority	I actually have seen a few cases of a more stable patient with a ruptured ectopic, and me really having to call and push the OB-GYN like it’s more of a let’s watch and wait … a patient will have to become critically ill in terms of like needing massive transfusion, or becoming progressively more hypotensive for them to really go to the OR and us having to push for that a little bit more.	EM
	I see it a lot of times in the sense of like trauma patients … there might be a condition like late second trimester terrible trauma, with … placental abruption … we can see a patient really circling the drain. But as an emergency physician wouldn’t be able to do anything about that unless the mother arrested.	EM
	You think it would never concern you, until you’re pregnant and get sick or have some condition where … pregnancy will be unsafe for you…. They think, “I can end the pregnancy, right? Because I have a medical problem?” … No, you can’t … the law says “prevent the death of the mother.” So just because you have that problem, and it’s probably going to progress to a situation that could be harmful for you, we can’t provide you with an abortion….	FM
	We’ve gotten into this sort of interesting space where a woman needs to be sick enough before we will offer her the care…. Straightforward lupus, no. Maybe established lupus nephritis, CKD 3, they would. So it’s variable, which can be difficult…. I feel sometimes it’s like playing God.	OB-GYN
	When you do values clarification exercises, one of the examples is always like the “last abortion,” where … you’re on a panel…. You have an abortion quota, and you can only do 1 more abortion. These are the 5 patients that want an abortion. Which one are you going to allow to have the abortion? … But we actually have that panel in [state]; that panel actually exists. And a bunch of doctors get together and sit around a table and decide who is deserving of an abortion. And the reason they do that is because the politicians of this state made a vague law because they’re not doctors, and they don’t know anything about medicine.	OB-GYN
	If I’m seeing someone in the office and, you know, I’m just doing a first trimester ultrasound, dating ultrasound or something. I’m looking, like, okay. It looks like … you may have an 8- or 9-week miscarriage. There’s no heartbeat. But I won’t offer her management based on that. I will send her for a formal ultrasound with radiology. Just because I feel like to cover my bases, I should have somebody else document that prior to me either offering her the D&C or giving her medication.	OB-GYN
Loss of patient autonomy and shared decision- making	I had a woman who … has 6 children and a desired pregnancy, and is like, “I’m trying to take care of my other 6 kids. And I have this like dead baby in my uterus. Can someone finally take care of me? I’ve been bounced around.” We tend to be able to provide that care, but I see that we’re like the third or fourth place that people are coming to.	EM
	I believe in patient autonomy and shared decision-making. And I think if there’s an instance where … an elective termination is technically what we’re doing, but it’s in the setting of a very likely miscarriage … there’s a lot less trauma, a lot less potential for bad outcomes for the patient…. That is where I see patients that are being impacted in a negative way.	EM
	I think we’re causing some harm in our patients by not being able to provide them what they want if they have a good understanding of … the diagnostic certainty.	EM
	I think I’ve always had a personal feeling where I wanted to give people a lot of certainty before I told them. But now I feel like it’s a legal obligation to do so. Like, I have to see this hCG going down, since you’re not immediately dying from this, before I can tell you … a D&C is an option. Whereas before, you know, if someone said, like, “I know my body … I’ve been through this 7 times before. I know I’m miscarrying, please get this out of me” … that ability to make that decision together with my patient is gone.	FM
	She’s like, “I think that this is an ectopic and I want to be treated with methotrexate,” and it’s like, “You’re probably right, but I actually can’t give that to you yet.” And that feels wrong…. It starts to feel really heavy … the risk to your license, risk of a felony charge, the risk to the patient. You’re just constantly like looking at it from every angle and trying to keep everyone safe, but … you have no wiggle room to make appropriate decisions.	OB-GYN
Erosion of trust in the patient- physician relationship	I think patients are also scared to talk to their doctors about their pregnancies because … people may think that their doctor might report them or something like that. So I think a lot of patients are not actually talking to their … OB or their family doctor about their unwanted pregnancy. I think they’re just getting on the internet and going to [abortion-protective state].	FM
	Some patients are very well aware, and they’re … showing up scared, and not sure who they can talk to. They’ll make appointments and just say it’s personal. They won’t let anybody else in the room, and they’ll tell me, “I’m pregnant, and I know abortion’s illegal here. What do I do?”	FM
	When … a patient … has an unexpected pregnancy, the conversation is far more guarded because … they are entirely warranted to have a mix of emotions. And if they decide to not keep the pregnancy that is their decision. But that is not something that they share with me. And it’s not something that I … push to find out…. There’s concern from patients that if they were to tell their doctor that they were intending to drive to another state for something … they could then be legally in trouble. That fear absolutely exists.	FM
	I think we’ve created some unintentional distrust of physicians because people are afraid of what to do or not to do.	OB-GYN
Increased health care system burden	I think it’s not always the best use of resources, and especially in a place where we don’t have Medicaid expansion and not everybody has access to health insurance … making somebody come back to the emergency room to repeat a beta or making somebody have another ultrasound in X amount of time when they have no health insurance to pay for that ultrasound…. We’re requiring patients to access resources that they don’t have access to.	OB-GYN
	We’re now finding it a little bit more difficult and having to consult OB. And, you know, longer wait times in the ED, longer stays, because things that were probably bread-and-butter emergency medicine now require the documentation of a board-certified OB-GYN to say … this is probably not going to develop into a normal pregnancy or normal delivery.	EM
	Sometimes it’s getting an extra ultrasound or getting an extra hCG for … confirmation … sometimes unnecessary or extra testing. I think we all have this fear of … not documenting well, and if somebody challenges us … there could be retribution … legally.	OB-GYN
	[Institution] has said that they will cover [out-of-state transfer costs] financially if the patient cannot … trying not to dump these costs on the patients. I don’t know that insurance is covering it. I suspect not…. I think it’s a huge financial drain on someone. Right now … it’s mainly the hospital that’s taking it just because we feel like we need to do the right thing.	OB-GYN

Abbreviations: CKD, chronic kidney disease; D&C, dilatation and curettage; ED, emergency department; EM, emergency medicine; EPL, early pregnancy loss; ER, emergency room; FM, family medicine; FH, fetal heart; hCG, human chorionic gonadotropin; OB, obstetrics; OB-GYN, obstetrics and gynecology; OR, operating room.

Medical management of EPL was also restricted. EM physicians reported being unable to prescribe mifepristone and misoprostol without OB-GYN consultation, and patients often faced barriers to obtaining them due to pharmacy restrictions.

A few EM physicians reported no change in ectopic pregnancy management, often because they routinely consulted OB-GYN physicians. One EM physician expressed that state-level exceptions were sufficient to guide timely care:

The [state] Medical Board released a statement … confirming that procedures to treat [ectopic pregnancy] are not abortions … we could do whatever was medically necessary ... didn’t have to wait until the woman was basically dying to intervene. That’s always been clear to me, but I guess it hasn’t been clear to others.

For most physicians, however, uncertainty regarding exceptions for ectopic pregnancy and PUL caused delays in treatment and increased risk of rupture, as expressed by an OB-GYN physician: “We’ve had patients … who clearly had ectopics … sat on for weeks until they’re clearly ruptured.”

Delays were also described in molar pregnancy, where fear of disrupting a potentially normal pregnancy led to hesitancy in diagnosis and treatment. Participants noted that radiology reports were more likely to include statements such as “cannot rule out normal intrauterine pregnancy,” even when findings were suggestive of molar pregnancy.

A few OB-GYN physicians reported that they could still offer abortion for previable PPROM at their institutions. However, most physicians stated that PPROM alone was no longer considered sufficiently life-threatening to allow intervention, and termination was allowed only in cases of sepsis, significant bleeding, or fetal demise.

Physicians also described challenges in managing pregnancies complicated by serious pregestational conditions including cardiac disease, autoimmune disorders, and hematologic disorders. Abortion restrictions created barriers to timely intervention, often requiring extensive deliberation before care could proceed. One physician described a patient with cardiomyopathy requiring intensive care unit–level care in the second trimester. Despite clear risk to the patient’s health of continuing pregnancy, the care team was required to secure written legal and multidisciplinary medical approval before intervening (Table 2).

Ambiguity and Fear Among Physicians

Physicians across all specialties described uncertainty regarding what constitutes abortion under the law, generating concern about legal consequences and influencing clinical decision-making. One FM physician described the uncertainty about management of PUL:

Doing a diagnostic [dilatation and curettage] … is really stressful…. Am I gonna go to jail for this? I have all of this data that says this is not … developing normally … it’s not in the uterus. But is that what matters? Is it gonna matter to a lawyer?

Another described confusion over management of even clearly diagnosed ectopic pregnancies (Table 2).

Gatekeeping and Shifts in Decision-Making Authority

Physicians described being placed into a gatekeeping role, requiring them to determine which patients qualified for intervention under restrictive legal frameworks. Physicians in many states emphasized that PPROM alone was no longer seen as sufficiently life-threatening to allow for termination. One OB-GYN stated,

They were not offering termination … unless the patient was ill, to whatever degree of illness you could consider being a threat to the life or vital organ of the mother … so patients were being expectantly managed until illness or viability. But before, even when those gestations were exceeding the legal gestation in [state], those were still being managed as potential life-threatening illnesses.

In ectopic pregnancy, clinicians described pressure to seek institutional or legal approval prior to emergent intervention. One OB-GYN recalled being questioned intraoperatively while managing a ruptured ectopic pregnancy:

I had a patient who was 11 weeks … it was a ruptured cornual ectopic … the fetus was still in utero with a heartbeat. But mom had 2 liters of blood in her abdomen…. In the middle of surgery, a partner said, “Have you talked to the ethics committee and legal before you effectively terminate this pregnancy?” I was like, “Well no, she’s hemodynamically unstable.” … That was pretty astounding … heartbreaking.

In pregnant patients with serious comorbidities, physicians described institutional processes requiring approval prior to intervention, which they described as uncomfortable and difficult to navigate.

EM and FM physicians described similar uncertainty in determining thresholds for intervention. One FM physician posed the question, “How ‘dying’ does the mom have to be to qualify for abortion?”

Loss of Patient Autonomy and Shared Decision-Making

Across scenarios, delays and restrictions limited physicians’ ability to provide patient-centered care and honor patient autonomy. In EPL, delays often forced patients into expectant management without choice. One OB-GYN explained, “A patient that may have wanted procedural management is now going to have a spontaneous miscarriage at home.… They are pushed to go the full 11 days, 14 days … it doesn’t feel like I am partnering with the patient as effectively or as kindly as I could.”

In ectopic pregnancy, PUL, and molar pregnancy, clinicians described being unable to offer treatment even when desired. A FM physician described a sense of obligation to diagnose EPL or ectopic pregnancy with certainty prior to intervention rather than engaging in shared decision-making with patients when clinical suspicion was high (Table 2).

Clinicians also felt constrained in counseling pregnant patients whose health was threatened by chronic illness. One OB-GYN stated:

If I have a patient who’s exceptionally sick, and I really think that they shouldn’t continue … the pregnancy … their life is at risk … because of chronic illness … I am limited in how I can counsel them, and I can’t … provide them with … resources for seeking termination.

Erosion of Trust in the Patient-Physician Relationship

Participants reported that these constraints affected trust between patients and physicians. Physicians across all specialties noted fear regarding abortion laws led patients to withhold health information or avoid seeking health care altogether. One EM physician recalled caring for such a patient:

She purposefully wasn’t getting prenatal care or information about the pregnancy … she didn’t want it documented in her record, because … she wasn’t sure what she was going to do. And that’s kind of sad … you should be able to get an ultrasound or bloodwork related to pregnancy and not be fearful that means you need to take that baby to term.

An FM physician similarly noted that patients avoided disclosing medical information due to fear of legal repercussions (Table 2).

Increased Health Care System Burden

Physicians described increased strain on health care systems and inefficient use of resources driven by legal risk rather than clinical need. In ectopic pregnancy and PUL, EM physicians noted increased emergency department (ED) utilization, including repeated visits for serial imaging and laboratory testing:

We’ll see people coming back for serial ultrasounds … in the emergency department…. We all know where this is going. We’re just waiting for the measurement to be right, or … for the specific date … to say that this is … incompatible with life.

They also described longer ED stays due to increased reliance on consultation. OB-GYN physicians also reported increased need for out-of-state hospital transfers and that hospitals were taking on the costs of these transfers.

Overall, abortion bans were associated with physicians’ limited ability to provide evidence-based counseling and medically indicated care to patients with comorbidities. Where exceptions could be made, institutional review processes were likened to gatekeeping of care.

Discussion

In this qualitative study, physicians across specialties described changes in clinical practice, concerns for patient outcomes and legal risk, and new gatekeeping roles when providing care in abortion-restricted settings. First, clinicians described circumstances in which abortion restrictions introduced added risk to patient health by delaying or denying timely management of early pregnancy complications. These findings align with existing research describing deviations from standard of care, delays until clinical deterioration, and “hesitant medicine,” as well as emerging evidence of increased maternal morbidity and mortality in states with abortion bans.^{5,9,10,12,16,17,18,19,20,21,22} Future research should examine differential impacts on Black, Latinx, and Indigenous populations, which are already experiencing the highest maternal mortality rates.^{5,22,23,24,25,26} Prior research has emphasized the profound emotional toll on patients denied timely care or required to go out of state to obtain it.^14,15,18 Our study extends this literature by illustrating how such delays unfold in practice and how clinical scenarios can transition from safe to unsafe when delays occur.

Clinicians described undermining of patient autonomy and the ability to engage in shared decision making, building upon existing physician accounts of constraints in counseling and harm to the patient-physician relationship.^9,11,12 Abortion bans increased the need for diagnostic certainty, institutional approval, or evidence of imminent maternal threat, shifting decision-making away from patients and physicians. While long-term consequences in this context are not yet known, it is known that denial of abortion is associated with long-lasting socioeconomic instability, poorer mental health outcomes, and increased risk of remaining in abusive relationships.^6,7,8 Loss of autonomy in abortion-adjacent care may similarly affect outcomes and warrants further study.

Another consequence was erosion of trust in the patient-physician relationship. Existing data are mixed, with some studies demonstrating loss of trust in clinicians and the medical system and others showing no significant change.^17,27 In this study, physicians reported that patients were hesitant to disclose health information, and some avoided pregnancy care altogether. This may deepen preexisting mistrust in reproductive health care, particularly among historically marginalized groups, rooted in the field’s history of abuse, exploitation, and coercion.^28,29 Loss of trust in clinicians may impair care and have lasting consequences for health care engagement.

Another prominent theme was ambiguity among both clinicians and patients surrounding legal permissibility and what abortion encompasses. Physicians reported uncertainty about which interventions were legally permissible, even if clinically indicated. These situations raised the question, “What is abortion?” and highlighted how intertwined abortion care is with reproductive health care more broadly. Notably, although many of the clinical scenarios discussed—such as management of ectopic pregnancy, molar pregnancy, or early pregnancy loss—may be described as abortion, participants did not consistently describe them as such. Instead, clinicians framed these interventions within condition-specific paradigms, which is consistent with professional guidelines and medical literature.^30,31 Abortion-adjacent care captures this disconnect between legal definitions and clinical practice, which shaped clinicians’ perceptions of legal risk and contributed to uncertainty and delays. Fear of liability led to hesitation and reliance on legal or ethics committees, further delaying care.¹⁸ These findings align with prior reports of widespread uncertainty across specialties, from OB-GYN to hematology-oncology to critical care.^9,10,16,17

Physicians expressed discomfort with the processes implemented to decide which patients were considered sick enough or which fetal anomalies were considered lethal enough to justify abortion under restrictive laws. They emphasized that these determinations were inherently subjective, ethically problematic, and not evidence based and described this gatekeeping role as inappropriate and harmful to the patient-physician relationship. As one physician explained, what once served as a hypothetical values clarification exercise—deciding which patients are deserving of care—has become a real process overriding clinical judgment (Table 2). Although these decision-making processes fall most directly into the scope of OB-GYN and were most frequently described by OB-GYN physicians, EM and FM physicians also encountered these scenarios and reported similar concerns, underscoring relevance beyond a single specialty. While prior work has documented clinician distress and moral injury in the post-Dobbs environment, this specific gatekeeping role is an emerging theme.³² Future work should examine how these judgment processes change over time and how they influence patient outcomes and clinician experience.

Finally, physicians described increased health care system strain, particularly in EM, including longer ED stays, repeated visits for serial testing, and increased reliance on specialist consultation driven by legal considerations. Prior research has similarly described increased time devoted to care coordination and transfers in this setting.⁹ These findings suggest that abortion restrictions may contribute to inefficiencies in care delivery as experienced by clinicians.

Limitations

This study has some limitations. As with all qualitative work, the findings rely on subjective participant accounts that may be infused with personal beliefs or recall bias. Participants self-selected into the study, which may lead to overrepresentation of those with the strongest opinions or particularly challenging experiences. Finally, we did not capture the perspectives of physicians who ultimately left states with abortion bans, whose experiences may differ meaningfully from those who remain.

Conclusions

In this qualitative study of physician-reported consequences of abortion bans across specialties, abortion bans were described as affecting care delivery far beyond what is traditionally categorized as abortion. The bans were associated with delays and barriers that endangered patients, eroded autonomy and trust, and placed clinicians into a gatekeeping role. Physicians highlighted the many areas of health care adjacent to abortion and ambiguity in its definition. Where decision-making was previously guided primarily by clinical judgment and patient values, care was increasingly shaped by legal risk. These changes may have lasting consequences, shifting focus away from patient-centered and evidence-based care, increasing strain on health systems, and exacerbating health care inequities.

Supplement 1.

eAppendix. Interview Guide

Supplement 2.

Data Sharing Statement