Implications of Dobbs v. Jackson for patients and providers: a scoping review
1School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
2Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
3Faculty of Health Sciences, University of Waterloo, Waterloo, ON, Canada
4Bayview Secondary School, Richmond Hill, ON, Canada
5School of Interdisciplinary Sciences, Faculty of Science, McMaster University, Hamilton, ON, Canada
6Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
*Corresponding Author, David T. Zhu, Virginia Commonwealth University School of Medicine, 1201 E Marshall St Richmond, VA 23298, Email: davetzhu@gmail.com, Phone: 256-951-2881Abstract
Introduction
On June 24, 2022, the U.S. Supreme Court’s decision in Dobbs v. Jackson overturned the right to abortion set forth by Roe v. Wade, granting states the authority to regulate access to abortion services. This has led to widespread bans, threatening patients’ access to, and healthcare providers’ abilities to provide, the full spectrum of reproductive health services. The ruling disproportionately affects marginalized groups, exacerbating existing social disparities in health and is an emerging public health crisis.
Methods
We conducted a scoping review to evaluate the impact of Dobbs on patients’ health outcomes and access to health services, as well as on medical trainees’ and healthcare providers’ ability to access abortion training and provide reproductive health services. The search was based on the PRISMA Extension for Scoping Reviews (PRSIMA-ScR) guidelines. We searched eight bibliographic databases (PubMed, Scopus, Embase, PsycINFO, Google Scholar, Science Direct, JSTOR, and Web of Science) and three preprint servers (medRxiv, bioRxiv, and Europe PMC) using various combinations of keywords related to ‘abortion’ and ‘Dobbs v. Jackson’ on March 22, 2023. Four reviewers independently screened the studies based on pre-specified eligibility criteria and one reviewer performed data extraction for pre-identified themes.
Results
A total of 18 studies met the inclusion criteria. We found that Dobbs led to a surge in demand for contraception, compounded existing travel- and cost-related barriers to access, increased polarizing views on social media (e.g., Twitter), and evoked significant fears and concerns among medical trainees regarding their scope of practice and fears of legal repercussions for offering standard-of-care and related services to patients seeking abortions.
Conclusion
Our study offers valuable insights into the clinical implications of Dobbs on patients’ health outcomes and access to health services, as well as providers’ reproductive health practices.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
The authors received no specific funding for this work.
1.Introduction
The U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization in June 2022 overturned nearly a half-century of the constitutionally protected right to abortion in the U.S. initially set forth by Roe v. Wade in 1973.1, 2 This ruling grants individual states the authority to regulate access to abortion care and reproductive health services with varying degrees of restrictions.1, 2 To date, approximately half of the U.S. states have imposed partial or complete bans on the provision of induced abortions.2, 3 Abortions are both safe and effective, and there is extensive global evidence that restricting access to legal abortions does not lower the overall rate of abortions; rather, it merely limits the rate of legal abortions, thus, increasing the rate of unsafe abortions, which are more prone to adverse health outcomes and complications.4, 5
The implications of Dobbs v. Jackson on patients’ health outcomes and providers’ ability to provide the full spectrum of reproductive health services have been harmful and widespread. Roughly 60% of women of reproductive age live in U.S. states that are “hostile” to abortions.3 A recent study predicts that a nationwide abortion ban would increase maternal mortality from childbirth or pregnancy complications by 21% in the general U.S. population and 33% among Black Americans.6 Dobbs is likely to stretch existing social and reproductive health disparities, given that abortions are disproportionately needed by patients from low-income backgrounds, those who identify with one or more racial/ethnic minorities, and other medically-underserved groups.7–9 Dobbs is also likely to exacerbate existing barriers to access abortion care, including cost and travel; e.g., those living in abortion-hostile states will likely need to travel out-of-state to access abortion or reproductive health services.10 The previous literature shows that women who are unable to terminate a pregnancy against their wishes were more likely to experience continued intimate partner violence (IPV) compared to those who had access to comprehensive services for pregnancy termination.11 This may also have collateral effects on other fields, such as healthcare provision for congenital diseases and neonates.12
To the best of our knowledge, there have been no other reviews that have comprehensively evaluated the clinical implications of Dobbs on patients and providers, likely due to the novelty of this health issue. To address this gap in the literature, we conducted a scoping review to overview the impact of Dobbs on (1) patients’ health outcomes or access to abortions and reproductive health services; (2) medical trainees’ access to comprehensive abortion training; and (3) providers’ ability to provide the full spectrum of reproductive health services.
2.Methods
2.1Methodological approach
We conducted a scoping review in accordance with the methodological framework created by Arksey & O’Malley13 and the PRISMA extension for Scoping Reviews (PRISMA-ScR) guidelines14 (Table S1) to capture both peer-reviewed and grey literature related to the clinical implications of Dobbs v. Jackson. Given the novelty and rapidly evolving nature of this topic, the flexibility and breadth of a scoping review is well-suited to address our research objectives.
2.2Information sources and search strategy
We conducted a literature search in eight bibliographic databases (PubMed, Scopus, Embase, PsycINFO, Google Scholar, Science Direct, JSTOR, and Web of Science) to capture published peer-reviewed studies, in addition to three other servers (medRxiv, bioRxiv, and Europe PMC) to capture preprint studies. Various combinations of the search terms “Dobbs”, “Roe”, “abortion”, “pregnancy termination”, “unintended pregnancy”, “abortifacient”, “misopristol”, “mifeprex”, “mifepristone”, “cytotec”, were used to retrieve articles on March 22, 2023. Given that the Dobbs v. Jackson ruling occurred in June 2022, we restricted our search from 2022 to 2023 to optimize our search. The detailed search strategy, including combinations of MeSH terms and Boolean operators, can be found in (Table S2).
2.3Selection of sources of evidence
Four reviewers (LZ, TA, NS, TB) independently screened the title and abstracts of retrieved articles based on pre-specified inclusion and exclusion criteria (Table 1). Abstracts were included. At this stage, studies that were classified as being potentially relevant subsequently underwent full-text screening by the same reviewers. The final subset of studies included in this review were verified and approved by all reviewers. Any screening conflicts that arose were resolve by a neutral fifth reviewer (DTZ).
2.4Data charting process and items
Following full-text screening, one reviewer (DTZ) performed data extraction and all other co- authors verified the data. Relevant information was collected and inputted into a data extraction form with prespecified endpoints such as the publication year, authors, study design, data collection period, data sources, methods and data analysis, and the main outcomes and findings related to abortion and reproductive health services. The data extraction template consisted of two sections (one for patient-oriented studies and another for studies involving medical trainees and healthcare providers). Preprints and abstracts remaining after screening were updated with their final peer-reviewed versions if available.
2.5Analysis, synthesis, and presentation of results
The final sample of studies were analyzed thematically, such as discussion of contraception [e.g., permanent contraception (PC), emergency contraception (EC), and other forms of contraception], facilitators and barriers that patients (and providers) face with accessing (and providing) care after Dobbs, health outcomes, public attitudes, and other relevant themes to abortion and reproductive health services in the post-Dobbs landscape.
3.Results
3.1Sample and article characteristics
Our initial search yielded 2,609 articles. Through automatic deduplication by Covidence, 936 articles were removed. Title and abstract screening removed another 1,638 articles and, lastly, full-text screening removed an additional 17 articles. Our final sample consisted of 18 articles (i.e., 12 full-text articles and 6 abstracts) which all underwent data extraction. Our screening process yielded a Cohen’s Kappa score of 0.82. An overview of our screening process is presented in (Figure 1). The study designs were predominantly cross-sectional (n=6), modeling (n=5), and observational (n=4), and additionally, there was one retrospective chart review, one NLP-based study, and one commentary (Table 2).
3.2Contraception
Seven studies (38.9%) in our sample discussed contraception (Table 2).15–20, 31 After Dobbs, we observed an increase in the demand for PCs. Notably, there was an increase in the number of Google searches for vasectomies immediately after Dobbs on June 24, 2022, as well as to a smaller extent immediately after the U.S. Supreme Court’s draft of Dobbs v. Jackson was leaked on May 2, 2022.16–19 The five states with the highest “vasectomy” search rates were Oklahoma, South Dakota, Idaho, New Mexico, and Hawaii.19 This is consistent with the increase of vasectomy requests, consultations, and procedures actually performed, identified using vasectomy billing data.15 Men who are younger (especially less than 30 years of age) and do not have children were more likely to seek vasectomy consultations after Dobbs was announced.15 Interestingly, the demand for vasectomies was inversely proportional to the ratio of urologists to adult men in states, therefore, Dobbs is expected to further strain the urological workforce in these states and increase delays.16 Similarly, there was an increase in the number of Google searches for “tubal ligation” after Dobbs, albeit to a lesser extent than for vasectomies.18, 19 The Northern and Southwestern regions of the U.S. had the highest surge in Google searches for vasectomies, whereas the Midwestern regions had the highest surge in tubal ligation searches.18
Similarly, the demand for ECs also surged after Dobbs (Table 2). The number of Google searches for “morning after pill” rose by approximately 8-fold after Dobbs and was most pronounced in Idaho, District of Columbia, South Dakota, Oklahoma, and North Dakota.19 Maintaining access to ECs after Dobbs is vital to mitigate a wide array of adverse health outcomes, e.g., a modeling study predicted that maintaining access to ECs after Dobbs for a theoretical cohort of 750,000 patients capable of pregnancy was associated with a reduction in 41,052 abortions, 11,168 miscarriages, 1,611 cases of preeclampsia, 3,839 preterm births, 4 maternal deaths, 83 neonatal deaths, and 34 neurodevelopmental delays; in addition, it was associated with an additional 13,634 quality-adjusted life-years (QALYs) and US$541,716,923 in healthcare expenditure savings.20 Most forensics nurses believed that Dobbs would not affect prescribing of ECs (79.77%), although a minority believed that EC prescribing would increase (6.94%) and an even smaller proportion believed that this would decrease (0.58%).31 Several nurses cited concerns about current or legal restrictions around EC prescribing after Dobbs (e.g., fear of prosecution).31
Additionally, the demand for other contraceptives increased after Dobbs (Table 2). The number of Google searches for “IUD”, “birth control pill”, and “condom” similarly spiked after Dobbs, albeit to a lower extent than PCs and ECs.19 Google searches for “IUD” were most pronounced in Utah, District of Columbia, Montana, Colorado, Minnesota, whereas Google searches for “condom” were most frequent in Delaware, New York, New Jersey, Connecticut, Mississippi.19 the modest spike in Google searches for “birth control pills” was suggested by the authors to be due to possible factors such as a lack of awareness, concerns about efficacy or side effects, cost-related barriers to access, or lack of convenience.19
3.3Medications
Two studies (11.1%) in our sample discussed the impact of Dobbs on medications other than contraceptives (Table 2).22, 26 One study found that requests for self-managed abortion medications via Aid Access, a telemedicine nonprofit organization that enables individuals to order abortion medications via mail,33 rose from 82.6 to 137.1 mean daily requests after the leaked draft of Dobbs on May 2, 2022, followed by a further increase to 213.7 mean daily requests after Dobbs officially passed.22 The requests rose in every U.S. state, although states that implemented total bans experienced the largest increase.22 The number of requesters citing “current abortion restrictions” as a primary reason increase from 31.4% to 62.4% after Dobbs, which tended to be most pronounced in abortion-hostile states but were also prevalent in states in which state laws governing abortion did not immediately change after Dobbs.22 Patients seeking teratogenic medications after Dobbs also faced difficulties. Notably, one study found that approximately 1 in 17 people experienced unexpected barriers to accessing methotrexate after Dobbs, of which 21.7% were directly related to Dobbs (e.g., prescription delays or refusals citing pregnancy risks or concerns related to abortion).26
3.5Public attitudes
Only one study (5.6%) of our study sample discussed public attitudes towards Dobbs (Table 2).25 By conducting sentiment analysis on tweets related to abortion and reproductive healthcare, they observed a growing polarization after Dobbs, in line with their expectations.25 Contrary to their expectations, this polarization was driven by a small (0.17 p.p.) increase in the proportion of overall negative/unfavorable tweets towards abortion and Roe v. Wade, as well as a modest (4.71 p.p.) decrease in positive/favorable tweets.25 These changes were most pronounced for tweets about “Roe v. Wade”, for which there was a 10.8 p.p. increase and 5.63 p.p. decrease in negative and positive tweets, respectively, followed by tweets about “family planning”, for which there was a 5.35 p.p. increase and 3.28 p.p. decrease in negative and positive tweets, respectively.25 Pro-life tweets typically centered around personal religious belief or support for conservative policies extending pro-life movements.25 In contrast, pro-choice tweets typically expressed anger and dismay with the Dobbs decision, highlighted the need for abortion, demonstrated fear over losing access to contraception after Dobbs, and perceived Dobbs as violating fundamental human rights for people capable of pregnancy.25
3.6Medical residency and fellowship programs
Three studies (16.7%) in our sample discussed the implications of Dobbs on medical trainees, residents, and fellows (Table 2).28–30 One study examined a sample of 286 obstetrics and gynecology (OB-GYN) residency training programs across the US and found that 38.8% of programs are located in states certain to ban comprehensive abortion care training after Dobbs, while an additional 5.9% are located in states likely to ban this training.30 This is equivalent to 43.9% of OB-GYN residents, totaling 2,638 individuals, that are training in programs located in states certain or likely to ban abortion after Dobbs.30 Significant concerns were brought up relating to the impact of Dobbs on restricting healthcare providers’ scope of practice. Notably, approximately 35.1-41.8% and 38.5-40.8% of residents and fellows in OB-GYN-related training programs across the U.S. believed that they would have to stop providing standard-of-care for induced abortion during the first and second trimester, respectively, after Dobbs.29 Similarly, approximately 38.5-40.8% and 62.3-63.0% expressed fear over facing charges for providing the standard-of-care for induced abortion during the first and second trimester, respectively, after Dobbs.29 This fear of legal consequences for providing standard-of-care abortion services was prevalent among residents and fellows after Dobbs, as evidenced by the following percentages: 48.4-51.2% for clinical management of abortion complications, 31.7-32.0% for early pregnancy loss care, 26.5-35.1% for caring for ectopic or molar pregnancies, and 31.2-38.2% for providing care using assisted reproductive technologies involving embryos.29 Maternal-fetal medicine (MFM) fellowship programs in abortion-hostile states are more likely to be associated with fertility and infertility (FI) centers, while MFM fellowships in abortion-friendly states are more likely to be associated with complex family planning (CFP) fellowship.28 Further, MFM fellows in abortion-friendly states are more likely to be female, participate in pro-abortion advocacy, and placed a higher emphasis on abortion-related training in their fellowship training.28
Discussion
To the best of our knowledge, this is the first scoping review that examined the clinical implications of Dobbs on patients and healthcare providers or trainees (e.g., medical residents and fellows). Our early findings contribute to better understanding how Dobbs has transformed the current landscape of abortion and reproductive healthcare, spanning various forms of contraception, access to medications and health services, social and environmental barriers (e.g., travel- and cost-related barriers to access), public attitudes, and medical training programs. In the nascent stages of the post-Dobbs era, our findings offer valuable insights into further avenues for clinical and public health research to characterize the longer-term consequences of Dobbs on people with the capacity for pregnancy, as well as informing policy priorities and interventions that need to be taken to safeguard patient outcomes and abortion providers’ practices.
Notably, studies15–20, 31 frequently described the impact of Dobbs on demand for, and access to, PCs (e.g., vasectomies and tubal ligation), ECs, and other forms of contraception (e.g., IUD, birth control pill, condoms, etc.). The number of Google searches for contraception spiked after Dobbs, corroborating with an increase in the number of consultations and actual vasectomies performed as per billing data,15 demonstrating a greater interest and demand for contraception after Dobbs. This emphasizes the need for widespread access to contraception, reliable sources of information to guide decision-making (e.g., trusted online websites or improving access to healthcare professionals to guide abortion care, reproductive health services, or complex family planning), and active efforts to combat misinformation related to contraception. Further, we consistently observed that demand for, and access to, contraception after Dobbs was relatively lower among states with more restrictive abortion laws.16, 18, 19 This is concerning given the disproportionately higher number of contraceptive deserts in abortion-hostile states, underscoring the importance of redoubling efforts to increase equitable access to contraception.34–36 Of further concern, we observed that patients faced new barriers to other medications such as methotrexate after Dobbs due to providers’ hesitancy or refusal to prescribe them since they are capable of being teratogenic.26 This foreshadows the rising collateral impact and encroachment of Dobbs on other fields such as oncology or rheumatology, calling for cross-specialty and collective efforts in the healthcare system to address this issue.
Further, travel and financial concerns were frequently cited as barriers to accessing abortion in the post-Dobbs landscape.21–24 This has been extensively documented in the existing literature, complicating access to proper care due to the geographical inaccessibility of abortion facilities,10 legal restrictions (e.g., requiring cross-state travel to access reproductive health services),37 time constraints,10 cost burdens for those need to take time off work and find childcare services,38 emotional distress,39 among other mechanisms.40 These barriers are most pronounced for historically marginalized and medically-underserved communities, such as those who are Black, Latinx, uninsured, undocumented, low-income, and others, who are also the populations who tend to face the most health complications and adverse health outcomes from an abortion.41 Preliminary evidence shows that Dobbs is likely to expand and compound these barriers and disparities,21–24 emphasizing the need for cross-sectoral, multi-level partnerships to address these social and environmental barriers to abortion care after Dobbs.36
Finally, studies28–30 frequently discussed medical trainees’ and healthcare providers’ concerns about the impact of Dobbs on their scope of practice, particularly since a large proportion of OB-GYN-related residency and training programs are located in abortion-hostile states. Fellows frequently cited concerns over no longer being able to legally provide standard-of-care services for patients in need of abortions and similar reproductive health services, as well as a fear of legal prosecution and charges for offering these services amidst the new restrictions under Dobbs.29 It is clear that Dobbs has already severely limited medical trainees’ abilities to receive training for, and healthcare providers’ abilities to provide, the full spectrum of reproductive health services in abortion-hostile states. There is an urgent need for further advocacy from healthcare organizations at the regional, state, and national levels to safeguard and expand access to reproductive healthcare training and provision.
There are several limitations to our study. Firstly, we conducted a scoping review less than a year after Dobbs passed with the aim of conducting an exploratory analysis and serving a hypothesis-generating foundation for further studies. As such, our data sources were limited and our findings are not intended to be representative of the general U.S. population. Further, we did not attempt to quantitatively synthesize the proportions and rates overviewed in our study, thus, a meta-analysis may be warranted. More research is warranted to comprehensively describe the implications of Dobbs on patients and providers at a national level with a longer follow up period. Further, one-third of our articles reviewed were only available in their abstract form, thus, our findings are not final and may be subject to change once the full-text articles are made available in the future. Secondly, our screening process involved four reviewers, which may have introduced inconsistencies. Although we achieved a relatively high kappa score (0.82) and attempted to mitigate these inconsistencies by training all reviewers (e.g., screening a subset of articles together to help achieve a more consistent reasoning process), this may have still affected the reliability of our screening and findings. Finally, we excluded qualitative studies as we wanted to focus our analyses on observational studies, therefore, a future review that reviews qualitative studies and identify key themes related to patients’ and providers’ lived experiences after Dobbs may be appropriate.
Conclusion
The clinical impact of Dobbs v. Jackson on patients’ health outcomes and access to health services, as well as providers’ abilities to continue providing the full spectrum of abortion and reproductive health services, is substantial. Further actions and research are needed from multiple spheres of action— healthcare providers, policymakers, legislators, public health agencies, and the public—to describe the consequences of Dobbs on the healthcare system and advocate for continued access to reproductive health services in the post-Dobbs landscape.
Data Availability
All relevant data are within the manuscript and its Supporting Information files.
Supporting information
Table S1. PRISMA-ScR checklist.
(DOCX)
Table S2. Systematic review search strategy (restricted between 2022-2023)
(DOCX)
Declaration of interests
We declare no competing interests.
Acknowledgements
Funding: No funding was received for this work.