Brain drain, skills loss, and other unintended consequences of overturning Roe v. Wade

Every day at the Kansas clinic where I perform abortions, I take care of pregnant people who have driven 10 hours or more across state lines for their procedures. They’re exhausted after moving mountains to get there: taking time off work, arranging child care, gathering funds. They’re excessively grateful, and their gratitude makes me sad. These are the lucky ones, I think. These are the few that have managed to get here.

My experiences caring for these patients are not unique. Over the past year, my colleagues and I at “The Nocturnists,” a health care worker storytelling podcast, have been interviewing abortion providers across the country for our new series “Post-Roe America,” which debuts Thursday. What really surprised me in all these interviews were the unintended consequences of the Dobbs decision, consequences that are just starting to emerge but will affect lives for decades to come.

I’m not talking about the wrenching stories you hear or read about every day, like the victims of rape and incest who have to carry pregnancies to term, further deepening their trauma by forcing them into pregnancy and birth. I’m not talking about the women who have discovered that their babies have fatal anomalies just a few months into their pregnancies and have been made to carry those pregnancies to term, just to give birth and have their babies die in their arms. I’m not talking about the pregnant people who present to emergency rooms hemorrhaging or septic from miscarriages and are told they’re not yet sick enough to have a procedure that will end their pregnancy to save their life.

Those consequences were all baked into the Dobbs decision. The authors of anti-abortion legislation and the Supreme Court justices who upheld those laws made a calculated sacrifice: Saving the lives of fetuses was worth any cost. Even when it means causing unimaginable psychological and physical harm to the pregnant people who have had no say in the violent stripping away of their bodily autonomy.

What the authors of anti-abortion legislation perhaps did not consider was the broader impact these restrictions would have on their communities. Many doctors we’ve spoken to are staying in their communities despite new restrictions on their life’s work. But others are making a different choice, leaving their homes because they no longer feel they can shoulder the moral distress of practicing health care in a system that does not uphold their values.

These physicians love their communities, but don’t feel like they can live there anymore amid all the injustice — and the pain and suffering it inflicts on their patients. They’re leaving their families, their communities, and their homes to start someplace new. And they’re taking their training, their compassion, and their expertise with them, leaving a void of care behind them.

Idaho, a state with some of the strictest abortion legislation in the country, has seen a massive brain drain of physicians who care for pregnant people just in the past year. In the northern part of the state, Bonner and Boundary counties now have no OB-GYNs for a combined population of 55,000 people. What we’re seeing is what we’ve always known: Where abortion is restricted, pregnancy will become more dangerous.

When you read about stories like this, it can often seem like an exodus: providers shunning their communities and walking away, toward a new or better life where they’re not so encumbered by the rules of their old communities.

But when you talk to them, it feels more like an exile. We talked to one provider from Tennessee, another state with a near-total ban, who loved her community. She was from there. She dreamed of raising her kids in the same place where she grew up, watching football on Sundays and sipping lemonade on the front porch. But she no longer felt safe there. She would have to risk criminal prosecution, her own liberty, and her family’s safety just to continue doing her work. So she left.

In the wake of these departures and the context of abortion restrictions, providers and medical trainees are losing opportunities to learn basic but lifesaving skills. An abortion procedure is the same as the procedure used for miscarriage. Many educators we spoke with expressed grave concern about the lack of training across the country for OB-GYNs and family doctors for whom a D&C, or dilation and curettage, was previously a core competency. Where abortion is legal, doctors can practice the procedure repeatedly in a controlled setting. Now, the first time doctors have to do this procedure will be in an emergency situation, when women are hemorrhaging or septic. Pregnant people will present to their doctors and the emergency room in need of care that doctors will no longer know how to provide.

Fortunately, health care workers and laypeople are taking notice. While I hesitate to speak of silver linings in the context of abortion bans, another unintended consequence of the Dobbs decision has been that the pro-choice movement, doctors included, are galvanized.

We spoke to an OB-GYN in Nebraska who never considered herself an advocate, an activist, or even an abortion provider. But now she’s speaking out. She’s organizing politically and professionally, and rallying her colleagues. We spoke to family doctors in New York City who have been tirelessly organizing, working with legal groups like the Center for Reproductive Rights to pass shield laws that protect providers in blue states who administer medication abortion across state lines.

Hopefully this galvanization among medical professionals will lead to further local and national wins for pro-choice candidates, and we can start the long haul of winning back the rights it took 50 years to dismantle. In abortion care we talk about how Roe was the floor, not the ceiling, meaning that Roe was never sufficient to protect reproductive rights or promote reproductive justice. In this next iteration, we’ll be more ambitious, and we’ll do better. I believe that over time, we’ll gain back the rights we had, and win many more that we could only have imagined. That would be the best unintended consequence of all.

Alison Block is a family medicine doctor, abortion provider, writer, and the co-creator and host of the podcast “The Nocturnists: Post-Roe America,” which launches today.