Opinion | Physicians vs Patients: Providing Abortion Care Post-Roe

In this video, Jeremy Faust, MD, editor-in-chief of MedPage Today, sits down with Jamila Perritt, MD, MPH, and Kristyn Brandi, MD, to discuss providing ob/gyn care in the post-Roe landscape. Perritt and Brandi talk through concerns from both physicians and patients around the country and correct some of the assumptions made in the “mass chaos and confusion.”

The following is a transcript of their remarks:

Faust: We’re going to be talking about abortion care in the post-Roe/Dobbs era, and I’m joined today by two awesome experts on this area who are going to enlighten us and update us.

One quick line of disclosure from ACOG [American College of Obstetricians and Gynecologists]. We have a lot of representation here, but this conversation does not reflect ACOG guidance or physician statements. We are educating an audience and giving this audience a chance to converse and listen to experts of the field.

Now, you both wear a lot of hats and do a lot of advocacy work. Sounds like those are full-time jobs, but you’re also both clinicians as well. Is that correct? So you have more than one full-time job, so hats off to you for that. Tell me about — I’m sort of flipping the order of what I thought I might do — I just want to know what you’re seeing in your practice pattern, and tell us also what state you work in and what the laws are like there, and what you have been seeing the past few months that is different.

Perritt: I’ll let you kick it off, Dr. Brandi, you go for it.

Brandi: Sure. As mentioned before, I’m an ob/gyn, and I specialize in family planning. So, I specialize in contraception and abortion care, and I provide that care in New Jersey.

I’m very fortunate to be in a state that just in the past year has passed legislation to help protect care, and we have very few, if any, restrictions on abortion access. That doesn’t mean that people just walk in and get the care that they need. There’s a lot of barriers, still, a lot of logistics that patients have to face in order to get care and that providers as well have to face in order to provide the care that they know is the right thing to do.

Faust: I’m curious because I used to work in New York, now I work in Massachusetts, and both states with a lot of rights. But especially when I worked in New York, where there wasn’t universal healthcare — in Massachusetts we have an amazing system where healthcare insurance and all that has really been in place for quite a long time. It’s not perfect, but it’s better than most places.

But when I worked in New York, I remember people didn’t even know they had access to care all the time. I’m wondering if in a place like New Jersey there’s that problem where people think, “Oh gosh, I heard that Roe was overturned and now I can’t do stuff.” Is there a sense that people are worried in your state more than they ought to be?

Brandi: Absolutely. There are times where we get calls to our clinic asking if our clinic is open still or if they’re X amount of weeks, can they get the care that they need? So even in a state that has legal protections around this care — and I will say, for now — we still have patients that have a lot of confusion, and providers [do] as well. There’s a lot of providers that don’t know what the rules are or if there are limitations in the care that they can provide. So for patients and providers, it’s really confusing, especially as things continue to develop.

Faust: OK, and please, let’s hear Dr. Perritt.

Perritt: Yeah. So, a couple of things. I’ll answer your question first and then maybe expand a little bit on the conversation that was just happening.

I provide clinical care in the Washington, D.C., area. So, I care for patients in D.C., Maryland, and Virginia. We are a small community, but mighty, of folks that are broadening access. In those three jurisdictions, the care that I’m able to provide as a board-certified ob/gyn is vastly different. If I’m working in D.C. compared to if I’m working in Virginia or if I’m working in Maryland, even though the distance is not that great, we see vast differences in legislation and policy and the care that people can provide, from parental consent notification laws to mandatory reporting laws to ages of consent. It really can vary.

That causes a lot of confusion for both patients and providers. One of the things that you mentioned is sort of if people are worried when maybe they shouldn’t be. I want to say without being hyperbolic that everybody should be worried, even if abortion is legal in the state that you practice now, if it’s legal in the community that you live in now, nothing is guaranteed.

That is really one of the implications of the decision, the Dobbs decision. This moving it back to the states means that your access to this care is dictated by the state that you live in. This is justice, or lack thereof, by geography. So there are no safe states, there are no sanctuary cities, and we really need to understand that very clearly, both as providers and also people in need of care.

The second thing that you mentioned that really resonated with me is Massachusetts being a highly-insured place. And D.C. is the same. We are a really highly-insured community. I’m not going to say “state,” and I won’t go into my D.C.-statehood advocacy at this moment, but for a number of reasons, regardless of what the will of the people in D.C. is, we are subject to congressional rule. That means that we don’t have control ultimately over the way that we spend our tax dollars and the decisions that we make.

But, we are a highly-insured city, so those things don’t necessarily go hand in hand. Just because abortion is legal and, in theory, your insurance covers it and you have access to it, it does not mean that it’s available or acceptable to you in its current form.

And so, as Dr. Brandi mentioned, one of the things that we’ve really been navigating, and this was long before Dobbs, is the implications for people that are seeking care, especially in communities that aren’t highly resourced.

So, you can live in a state like Massachusetts, you can live in a state like New Jersey, in D.C., you can live in a jurisdiction like D.C., have insurance, have an abortion provider in your community, and still not be able to access that care, whether it’s legal or not. So really being cognizant of all the barriers that folks face is a critical part of what we do organizationally and the way that I and I know Dr. Brandi approaches her work.

Faust: OK, I want to tap next into both your expertise and the opportunity that you both have as leaders.

A lot of people think that when you’re leading, you’re just spreading information, which is true. You’re doing that, but a lot of times people in your position are also really in a great situation to receive information. People come to you and they want to tell you things, and that kind of gives you a lot of perspective and the ability to then kick it back out.

Now, having said that, we are each in situations that are relatively better than some areas. What are you hearing from places around the United States from providers and from patients who are really in places where things have changed dramatically overnight this year?

Perritt: I love that you lead with this conversation about bidirectional learning as a component of leadership, because it is so critical. I know for me, I’ll use “I words.” As a medical student and a resident, that piece of training is not always emphasized in the same way, right? You can only be an effective leader if you know how to listen, if you know how to be quiet, if you know how to receive information. That is absolutely true in this moment in time.

I live in, as I mentioned, the D.C. area. So for me to really know what’s happening in Texas and Mississippi and Alabama and California and New Jersey, we rely on the doctors in our network. At PRH [Physicians for Reproductive Health], we’ve trained more than 500 doctors through our leadership training academy, which brings doctors together to teach them how do you use your white coat to advocate for your communities and for your patients.

We are a national organization, and we have doctors in almost all 50 states, so we rely on the doctors that are working in community with advocates, with activists, with patients, with healthcare systems to talk with us about what it is that they’re seeing. Overwhelmingly, folks are experiencing mass chaos and confusion at the healthcare delivery level.

And part of it is by design, right? These laws, these piecemeal, patchwork types of legislation are designed to cause chaos and confusion so that people do not access that care.

So a large part of what we are doing is really talking with the doctors in our network, talking with the supporters and the advocates in our network, about what is happening in their own community and how to keep themselves safe and how to support safe spaces for the communities that they care for, especially in this moment when we know that there is an appetite to punish and penalize both patients and doctors for taking care of people.

Brandi: Yeah, I would echo a lot of that. At ACOG we have thousands of ob/gyns that we’re hearing from across the country, and everyone’s experience is different, but a lot of the themes that we’re hearing are just mass confusion and trying to figure out how to navigate all of these new laws and be able to provide just care for our patients.

Many providers right now are in this really difficult space of “Do I intervene? There’s an emergency, I know what to do. I have the clinical skills that I know I can use, but do I call my lawyer first? Do I make sure that it’s legally acceptable for me to provide the care that I know that is evidence-based, that is the right thing to do? Or do I protect myself?” Which is a very reasonable thing.

For example, I think we think about this a lot in the space of abortion provision, which is clearly where my heart is, but there are so many other providers: high-risk maternal-fetal medicine providers, people that are ER physicians, people that are engaging in this in so many different ways. It’s really challenging to try to navigate how we provide care knowing that if we face the consequences, if we go to jail, if we’re criminalized, that also means that the community may lose that provider, that that provider won’t be able to provide the prenatal care that’s needed, the gynecologic care that’s needed in that space. That’s a really challenging place to put providers in right now.

We’re hearing stories — there’s 65,000 members of ACOG — so we’re hearing from thousands and thousands of ob/gyns in all different kinds of spaces that may not really have engaged in this work before, that may not have said the word “abortion” or talked about it in the past, but are now having to figure out how to explain what’s happening on the ground with their patients.

I also wanted to echo the fact that we’re hearing this not just from providers, but from patients in their stories, and I think that’s been a really powerful message in the past couple of months since this has happened. But we’re also [hearing] from all of those grassroots organizations that have been doing this work for such a long time, the groups that are providing funding for abortion, that are providing logistical support for people that are traveling, they’ve been doing the work for a long time, and we need to listen to those voices as well so that we can figure out what is the best way to move forward.

Perritt: I love that, Dr. Brandi.

I actually want to move a little bit further, because I think it’s not just a difficult position that providers are being put in and patients are being put in, but what’s actually happening is that patients and providers are being pitted against one another.

Because what’s happening is that now I’m no longer making decisions about what I think is best medically for you or making recommendations about your health and wellbeing. I am prioritizing my safety, myself, before the recommendations that I’m providing you. Right? Because this risk of criminalization, this threat of arrest and imprisonment of doctors is not theoretical.

We have seen this play out in this country in the past, and so it’s not an academic exercise, it’s something that we have to take seriously. It’s something that a lot of the providers that we hear from on the ground are taking seriously. So the example that Dr. Brandi gives of a patient showing up and you’re making a decision about the care you provide, but are deciding whether you should call your lawyer first, is something that we know is happening today on the ground in states where abortion is banned.

For people coming in with pregnancy loss and miscarriage — this idea that abortion was not relevant or as an issue to most people was always false, because nobody thinks they need an abortion until they need an abortion, and no one thinks that they need miscarriage care until they have a miscarriage. So many of the ways that we care for miscarriages or pregnancy loss and abortion care are the same thing.

When you are threatening one body of work, one section of care, our ability to care for people in one component of their life, it absolutely impacts the other.