What the End of Roe v. Wade Will Mean for the Next Generation of Obstetricians

For a long time, Cara Buskmiller has known two things about herself: she wants to deliver babies, and she is called by her faith to a lifetime of virginity. Growing up in nineteen-nineties Dallas with six younger siblings, Buskmiller knew a little about pregnancy and birth, and was interested in medicine. But she truly decided on obstetrics in the seventh grade, after touring an ob-gyn’s office with her Girl Scout troop. She saw posters promoting contraception on every wall—something her parents, devout Catholics, had taught her was wrong—and she thought, Oh, my gosh, I have to become an OB to combat this!

Her second vocation took longer to discern. She tried dating in college, carefully considering all the eligible Catholic men she knew, but no one felt like an obvious match. She flirted with the Catholic Church’s version of a sorority rush for nuns, visiting convents and chatting with sisters to see whether that should be her path. But it turned out that the answer was in her own family: her great aunt Marjorie, a former teacher, was a consecrated virgin, dedicated to chastity and obedience while also able to pursue an independent professional life. Today, Buskmiller is unfazed by questions about why a professed virgin would specialize in a field of medicine that’s all about sex. “Doesn’t God have a sense of humor?” she asked, chuckling.

But in 2010, as Buskmiller prepared to apply to medical school, she worried that admissions committees would be skeptical of her beliefs, and how her personal objections to abortion and birth control would affect her practice as an ob-gyn. What would program directors think of the volunteer stints she’d done at a crisis pregnancy center? And, when it came time for residency, would she be able to duck out of certain clinical rotations to avoid assisting with abortions?

Buskmiller got into medical school at Texas A. & M., and she went on to do her residency at St. Louis University, a Catholic school. But she felt that students like her needed more backup. So, during her second year as a resident, she launched a Web site called Conscience in Residency, a support network for doctors-in-training who have moral objections to abortion. The site’s tagline is “You’re not crazy, and you’re not alone.” Buskmiller maintains a crowdsourced spreadsheet where residency candidates note which institutions made them feel welcome—and which ones didn’t. An “abortion ‘mecca,’ ” someone commented about Oregon Health & Science University, in Portland: “Two faculty members stated directly in medical student lectures that they think anyone holding a conscientious objection to abortion should reconsider if it’s ethical to be an ob-gyn.” Another commenter wrote, of Southern Illinois University, in Springfield, that the program director “seemed very shocked when I asked about opting out of sterilizations.” Most of the residents, the commenter added, “are very involved in ‘abortion advocacy.’ ”

Even in an era when Roe v. Wade looks likely to be overturned, residents who describe themselves as pro-life are countercultural within their field. They believe that fetuses are human persons with moral status; when Buskmiller encounters a woman in even the earliest stages of pregnancy, she sees two patients, not one. The American College of Obstetricians and Gynecologists, or ACOG, on the other hand, firmly maintains that abortion is a form of health care and supports the right of a patient to terminate a pregnancy before fetal viability. Progressive physicians and students argue that abortion access is not just crucial for their patients’ health but for a more economically and racially just society. They believe that abortion can help keep families out of poverty and that it protects the lives of Black women, who, according to the Centers for Disease Control and Prevention, are three times as likely as white women to die from pregnancy-related causes. Meanwhile, residency-program directors may hesitate when they encounter students who decline to participate in abortion training, which involves learning how to care for patients in emergencies as well as before and after the procedure. Even doctors who don’t perform abortions are likely to encounter patients who have had them. Knowing more about that experience makes them better practitioners, Jody Steinauer, an ob-gyn professor at the University of California, San Francisco (U.C.S.F.), said.

Still, there’s a surprising amount of subtle variation among how people in the medical community think about this issue. All students and young doctors have to sort out questions of how they want to practice medicine; aspiring ob-gyns’ views on abortion might determine what training they seek out, which specialities they pursue, and where they choose to live. In a post-Roe world, that self-sorting process would grow even more intense: in roughly half the country, abortion would be all but illegal, according to the Guttmacher Institute, a reproductive-rights think tank. Medical residents in those states would likely have to go elsewhere to learn about abortions, just as patients would have to travel to get the procedure. In the other half of the country, demand for abortions would almost certainly shoot up, putting pressure on physicians, hospitals, and clinics to serve patients from out of state. For all doctors and trainees, no matter their views, this geographic divide could pose dilemmas—even for anti-abortion students who would presumably welcome the reversal of Roe. Simple slogans and tidy categories are useful for politics but not for medicine. “Pro-life people do not understand why gynecologists talk about the need for abortion until they see a woman dying in front of their eyes because they’re pregnant,” Buskmiller said. “I think it’s possible to be pro-life, in spite of those situations. But we can’t have rose-colored glasses and think the situation is easy. It is not.”

Doctors haven’t always seen abortion as a form of health care. The text of Roe v. Wade hints at the differences among physicians in the early seventies; the Supreme Court took it for granted that some doctors would object to abortion for either moral or religious reasons. Feminist scholars have noted that the Justices seemed just as preoccupied with physicians’ rights as they were with women’s rights. “The abortion decision in all its aspects is inherently, and primarily, a medical decision, and basic responsibility for it must rest with the physician,” Justice Harry Blackmun wrote in the opinion of the Court.

Around the time that the Court was assessing the case, however, a hundred doctors signed a letter advocating a new, patient-centered approach to health care. “It will be necessary for physicians to realize that abortion has become a predominantly social as well as medical responsibility,” they wrote. “For the first time . . . doctors will be expected to do an operation simply because the patient asks that it be done.” They were arguing for a new way of thinking about medicine: at least when it comes to pregnancy, doctors shouldn’t be the deciders. Patients should.

It took many years for medical schools and health institutions to adopt this attitude. In the decades after Roe, “contraception was not considered to be a training topic worthy of an ob-gyn,” Eve Espey, the chair of the ob-gyn department at the University of New Mexico School of Medicine, told me. “Abortion was just taboo. It was felt to be an activity that was dominated by older men for a profit motive.” Even by 1992, just twelve per cent of ob-gyn residency programs included training on abortion procedures.

In the early nineties, however, a major shift began—one led, in part, by students. In 1993, when Steinauer was a medical student at U.C.S.F., she founded an organization called Medical Students for Choice, with the goal of expanding abortion access. Many doctors who had started practicing before Roe, Steinauer told me, provided abortions out of necessity: they had seen women die and were committed to preventing that from happening again. “I would say my generation started thinking about it a little differently,” she said. “It was a little more activist- and advocacy-oriented.” They didn’t want a woman’s right to an abortion to be merely theoretical.

The best way to expand access to abortions, Steinauer believed, was to train more doctors to perform them. She and her fellow-students began lobbying the Accreditation Council for Graduate Medical Education to make training on elective abortions mandatory for ob-gyn residency programs, and in 1995 this became the standard—all residents had to learn about abortion. But the next year, after pushback from Catholic hospitals and other groups, Congress passed an amendment to a public-health law, prohibiting discrimination against medical-training programs that refused to teach abortion procedures. The amendment underlined a growing tension in the field: legally, no one could be forced to perform abortions. But, culturally, pro-choice voices were growing louder within the world of obstetrics, arguing that abortion is a necessary part of reproductive health care.

In 1999, Susan Thompson Buffett, the wife of the multibillionaire Warren Buffett, bankrolled a new initiative called the Ryan Residency Training Program, which provided funding, curriculum help, and other resources to residency programs that teach abortion procedures. When I spoke with Steinauer, the director, she said that, as the program became more widely known, students who were serious about family planning began asking about Ryan rotations in their residency interviews: “They saw it as a core part of their identity as ob-gyn physicians.” (A sister program, RHEDI, also provides family-medicine programs with resources to train residents about abortion.) Now, if a medical student wants to focus on providing abortions, she can choose from more than a hundred programs that follow the Ryan model, which has been adopted by roughly a third of ob-gyn residency programs. She’ll learn how to counsel patients on birth control and medication that can induce abortion in the early weeks of pregnancy, and, at some point in her training, she’ll likely perform dilation and evacuation on patients in their second trimester of pregnancy, a process that involves opening a woman’s cervix and removing the fetus. If the student wants to learn how to perform abortions on patients in complex medical situations, including those who are far along in their pregnancies, she can pursue a fellowship in complex family planning—a specialty that became fully accredited only two years ago.

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