Effects of the Dobbs v Jackson Women's Health Organization Decision on Obstetrics and Gynecology Graduating Residents' Practice Plans

Abstract

OBJECTIVE: 

To explore the association of the Dobbs v Jackson Women's Health Organization (Dobbs) decision on future practice locations of graduating obstetrics and gynecology residents.

METHODS: 

This is a mixed-methods survey study of obstetrics and gynecology residents graduating from sites with Ryan Program abortion training programs (109 sites) between March 8, 2023, and April 25, 2023. We conducted both univariate and multivariable logistic regression analyses to identify factors that were associated with post-Dobbs change in career plans, particularly location. We also performed a thematic analysis using responses to the survey's optional, open-ended prompt, “Please describe how the Dobbs v Jackson Women's Health Organization decision impacted your professional plans.”

RESULTS: 

Of an estimated 724 residents graduating from residencies with Ryan Program abortion training programs, 349 participated in the survey (48.2% response rate); 17.6% of residents indicated that the Dobbs decision changed the location of intended future practice or fellowship plans. Residents who before the Dobbs decision intended to practice in abortion-restrictive states were eight times more likely to change their practice plans than those who planned to practice in protected states before the Dobbs decision (odds ratio 8.52, 95% CI 3.81–21.0). In a thematic analysis of open-ended responses, 90 residents wrote responses related to “not living in a state with abortion restrictions.” Of residents pursuing fellowship, 36 indicated that they did not rank or ranked lower programs in restrictive states.

CONCLUSION: 

These findings demonstrate reduced desire of residents in obstetrics and gynecology to practice or pursue fellowship in restrictive states after residency. This reduction in obstetrics and gynecology workforce could significantly exacerbate maternity care deserts.

In Brief

Among 349 graduating obstetrics and gynecology residents, 17.6% reported changing the location of intended future practice or fellowship plans after the Dobbs decision.

The U.S. Supreme Court's decision in Dobbs v Jackson Women's Health Organization (Dobbs) in June 2022 overturned 50 years of federal abortion protection under Roe v Wade. This has resulted in dramatic effects for pregnant people seeking abortion in the United States through the removal of the constitutional right to this service. The decision has also affected health care professionals.¹ From the training perspective, in August 2022, investigators reported that 43.9% of obstetrics and gynecology residents were training in states with predicted abortion restrictions.² Subsequently, a study by the Association of American Medical Colleges on the 2022–2023 residency application cycle demonstrated a 5.2% drop in obstetrics and gynecology applicants overall, with the largest drop (11%) in applicants at programs in states with complete abortion bans.³

Founded on a predicted antagonism between abortion restrictions and obstetrician–gynecologists (ob-gyns) being able to provide evidence-based medicine in a legal manner,⁴ lay concerns regarding ob-gyns leaving states with restrictions^5,6 have now become a reality. A 2023 survey found that 40% of ob-gyns practicing in Idaho, a state with a complete ban, are considering leaving.⁷ Furthermore, a lay press report documented Texas obstetrics and gynecology health care professionals leaving the state or quitting medicine altogether as a result of the pervasive toll of abortion restrictions.⁸ Documenting the effects of abortion policy and punitive legislative threat on the medical workforce can inform the public and legislators of the effects of these laws on a broad range of health care services.

Residents graduating from programs in June 2023 will be the first to have their career plans affected by the Dobbs decision. We hypothesized that the Dobbs decision may have changed the practice location of choice for some graduating residents. We aimed to assess the effects of the U.S. Supreme Court's removal of federal protections for abortion rights on career decisions of residents graduating from obstetrics and gynecology residencies with Ryan Program abortion training programs.

METHODS

We conducted a mixed-methods study using an online prospective cross-sectional survey with both quantitative questions and an open-ended qualitative query to investigate how the Dobbs decision affected plans for graduating residents' postresidency job or fellowship. We invited all residents graduating in June 2023 from residencies with Ryan Program abortion training programs to participate (n=724). This represents about 50% of obstetrics and gynecology residents overall (n=1,427) when using data from the most recent Accreditation Council for Graduate Medical Education (ACGME) 2021–2022 report.⁹ At the time of this study, the Ryan Program supported abortion and contraception training in 109 of 302 ACGME-accredited obstetrics and gynecology residency programs in 37 states.¹⁰ Although abortion training has been a core education ACGME requirement in obstetrics and gynecology programs since 1996, many residency programs use the Ryan Program to assist various aspects of this training.¹¹

We excluded residents not graduating in June 2023 and those graduating from residencies without Ryan Program abortion training programs. We focused on residents graduating from residencies with Ryan Program abortion training programs because this provided rapid access to a large number of obstetrics and gynecology residents connected through an established Ryan Program listserv. Furthermore, as mentioned, residents who elect to participate in the Ryan Program may be more likely to be invested in abortion care in their future careers.

Our survey invitation stated that our intended goal was to understand graduate postcareer plans, “and their relation to the overturn of Roe v Wade on June 22, 2022,” but provided no other background information. The 37-item survey started with questions about demographics (age, sex, race and ethnicity, relationship status) and then transitioned into questions regarding postresidency plans and how those plans changed in light of the Dobbs decision. Of note, race and ethnicity were collected in provided categories (with options for “other” and “prefer not to answer”) with the goal of assessing whether changes in plans after Dobbs were associated with this variable. It is important to note that residents were asked to report what state they were planning on practicing in or ranking highly for fellowship before Dobbs and then asked whether Dobbs changed this location. Those who reported a post-Dobbs location change were asked to report their new intended state of practice or state highly ranked for fellowship. Using Likert scales, we then assessed their plans to provide abortion, personal stance on abortion, future pregnancy plans for self or partner, desire to advocate for abortion access, and how strong of an effect each of these variables had on career decisions. These variables were decided on by the primary research team after collective brainstorming. The survey ended with the following optional, open-ended prompt: “Please describe how the Dobbs v Jackson Women's Health Organization decision impacted your professional plans.” Questions were developed de novo by the research team. All survey questions except the open-ended prompt required a response (Appendix 1, available online at https://links.lww.com/AOG/D402). Content validity of the questions was maximized by distribution of survey questions for development to all experts in family planning at our institution and Ryan Program leadership. Furthermore, the survey was beta tested by our institution's third-year obstetrics and gynecology residents with their feedback incorporated into survey revisions.

We designed the survey to take about 15 minutes. We collected and managed study data using REDCap (Research Electronic Data Capture), a secure, web-based software platform designed to support data capture for research studies.¹² To maintain anonymity, survey residents concluded the survey with a link to a separate REDCap survey to enter their email to receive a $20 Amazon gift code by email. A study member without access to the survey data sent these gift codes for compensation by email.

We distributed surveys through multiple methods from March 8, 2023, to April 25, 2023. The Ryan Program national office emailed an invitation with a link to the survey to 93 residents (from 36 Ryan Program abortion training programs) who had previously agreed to further email contact after completing a Ryan rotation. Subsequently, the Ryan Program national office also contacted individual Ryan Program residency program directors to forward the surveys to their residents. Finally, the research team sent survey invitations by both email and regular mail to residency directors of programs with Ryan Program abortion training programs to forward to their residents.

For analysis of our quantitative data, χ², Fisher exact, and t tests were used to detect univariate relationships between demographics and changing post-Dobbs plans. We used multivariable logistic regression to examine the likelihood of changing future practice or fellowship state after the Dobbs decision based on the preidentified variables mentioned previously: stance on abortion, plans to incorporate abortion care into practice, plans to advocate for abortion access, personal or spousal pregnancy plans, and personal or spousal access to abortion. States' abortion restrictions were categorized with the Guttmacher Institute's abortion restriction map in the post-Dobbs period.¹³

We performed a descriptive thematic analysis^14–16 of the free-text responses from the survey's optional, open-ended prompt.¹⁷ A member of the research team imported these responses into Maxqda 2022, and two coders (A.L.W., J.B.) inductively generated codes from the first 50 responses. The two coders then reviewed their generated codes, generating an initial codebook, and consensus coded the remaining responses. We revised and expanded the codes as we went and then grouped codes into thematic categories. The University of Utah IRB considered this project exempt, given that it had no greater than minimal risk and fit within its exempt category 2, research that includes only survey procedures.

RESULTS

Of an estimated 724 residents graduating from residencies with Ryan Program abortion training programs, 349 (48.2%) participated in the survey. Three participants did not complete the entire survey. Residents from 99 of 109 residencies with Ryan Program abortion training programs responded to the survey (90.8% of programs represented). Of residents, 182 indicated that they were planning to be generalist ob-gyns (52.1%) and 143 indicated that they would be pursuing fellowships (40.9%). Table 1 indicates respondent demographics and future practice or additional clinical training plans. Of residents, 17.6% indicated a change in intended practice location from before to after Dobbs. A smaller number of residents, 23 (6.6%), reported a change in future practice type from before to after Dobbs. In addition, changing state of practice was related to state-level abortion restrictions (P<.001), personal access to abortion care (P<.001), and changing practice plans (P=.03). In the multivariable analysis, those who before Dobbs intended to practice in abortion-restrictive states were 8.52 (95% CI 3.81–21.0) times as likely to change their state of future practice as those initially intending to work in protective states after the Dobbs decision. Furthermore, those who planned to provide abortion care before Dobbs were 4.24 (95% CI 1.67–12.2) times more likely to change their state of future practice. These findings are summarized in Table 2. Of residents, 82.0% (n=284) indicated that they want to “strongly advocate for abortion access for patients,” and 33.4% (n=95) of those intend to work in abortion-restrictive states.

Table 1.: Demographics of Residents Graduating From Residencies With Ryan Program Abortion Training Programs and the Univariate Relationships Between Demographic Variables and a Resident Changing Their Intended State of Future Practice After the Dobbs v Jackson Women’s Health Organization Decision

Table 2.: Multivariable Analysis Predicting Whether a Resident Graduating From a Residency with a Ryan Program Abortion Training Program Changed Intended Practice State After the Dobbs v Jackson Women’s Health Organization Decision

Of residents who completed the quantitative survey, 183 (52.8%) wrote responses to the nonrequired, open-ended prompt, “Please describe how the Dobbs v Jackson Women's Health Organization decision impacted your professional plans.” We present the thematic analysis in Appendix 2, available online at https://links.lww.com/AOG/D402, with exemplary quotes included. The most common theme (n=90) was that residents were not willing to live in a state with abortion restrictions. This included 36 of 143 residents applying to fellowship programs who indicated that they ranked programs in restricted states lower or did not rank those states at all. Notably, this affected the decisions of residents whose chosen specialties are not as obviously affected by abortion restrictions such as reproductive endocrinology and infertility and gynecologic oncology. Another theme emerged about the consequences of avoiding a move to a restrictive state. Some residents (n=14) lamented that abortion restrictions meant that they chose not to move to their home state as originally planned, and they shared that this meant missing out on being close to their families.

Furthermore, some residents commented on their avoidance of restrictive states because of a concern regarding their personal (or spouse's) future pregnancy plans (n=14). Finally, several residents voiced that the Dobbs decision motivated them to increase their advocacy for abortion access (n=35) and, even more, to provide abortion care (n=47). Several residents specifically mentioned a desire to work at Planned Parenthood after the Dobbs decision.

DISCUSSION

Our study sheds light on the effects of the Dobbs decision on the career plans of obstetrics and gynecology residents graduating from residencies with Ryan Program abortion training programs. In our quantitative analysis, 17.6% of residents changed their intended practice state after the Dobbs decision, with those who initially intended on practicing in restrictive states being more than eight times time more likely than those initially intending on practicing in protected states to have changed their intended practice location. Factors associated with changing state of future practice included originally intending to practice in a restrictive state, plans to provide abortion care, and personal reproductive concerns.

The free-text thematic analysis allows further insight into our findings, with 90 residents, unprompted, voicing an unwillingness to live in a state with restrictions. Furthermore, we saw that for 36 fellowship-bound residents, even those not destined to perform abortions, the Dobbs decision greatly affected their ranking of programs. These responses illustrate the complexity surrounding decisions concerning where to live and work and how abortion restrictions interplay. Although it may be harder for established physicians to move given both established practice and personal concerns, it is likely easier for physicians beginning their careers to make active decisions in avoiding a restrictive state. Given this, the long-term effects of these early career decisions may be considerable. To further explore the effects of the Dobbs decision on resident decision making, our team is currently conducting additional qualitative study through in depth semistructured interviews of respondents who consented to further contact to further explore these themes.

Our findings may not be generalizable to all obstetrics and gynecology residents, particularly with our response rate of less than half (48.2%). In addition, our study includes only residents graduating from Ryan Program abortion training programs, who, as mentioned, by attending a program with dedicated abortion training and education, likely represent those with the highest interest in Dobbs-related effects. These residents are also more likely to have considered how state-level restrictions since Dobbs would affect their future practice. Furthermore, almost half of our residents were fellowship-bound (143/349, 41%), whereas recent studies indicate that about one in four residents subspecializes.¹⁸ Specifically, the residents in this study represent 34.7% of all 2023 obstetrics and gynecologist fellowship match positions (n=412).¹⁹ This larger proportion of subspecialty-bound graduates might bias our study toward those interested in abortion care, particularly given the inclusion of maternal–fetal medicine and complex family planning. Although this lack of generalizability is a limitation of our study, this sampling of residents more likely to be invested in abortion care highlights the likely continued decrease of people experienced in and willing to provide abortion care in restrictive states. We are investigating other means of repeating our study with a more representative sample of all residents.

Other limitations of our study include the fact that we had no built-in protection against a participant completing the survey multiple times, given that most surveys were sent indirectly to residents. Furthermore, because the survey was sent to many participants directly and indirectly by the Ryan Program, we must consider a possible bias in participant responses, leaning favorably toward abortion access, to please the sender. We do not believe this is the case, however, given that the majority of residents were sent the survey forwarded from their Ryan Program or residency program director. Finally, given the significant time that it took to create and beta test our survey, it was first distributed in March 2023. We acknowledge that at this time many residents had already matched to a fellowship or signed job contacts, and this makes their responses a retrospective reflection.

It is reassuring that the Dobbs decision has not caused a decrease in dedication by ob-gyns to provide and advocate for abortion rights. In fact, for many people, it appears to have increased motivation to advocate, including those destined to work in restrictive states. We fear, however, that this motivation and dedication might not stave off the realities of living and working in an abortion-hostile environment.²⁰ We urge hospital-level administrators, particularly in restrictive states, to heed the concern of impending “brain drain” of physicians who can safely provide not only abortion care but also evidence-based pregnancy and miscarriage care. Graduate medical education leadership may use these data to inform tailored recruitment methods and to increase support from their medical systems. Finally, we hope these findings will be useful when providing evidence to state policy makers in states where there is a desire to have hospitals and institutions that are national leaders in health care. If they wish to retain and recruit physicians who can care for the population in their state, they must understand how important abortion access is to their health care workforce.