What it takes to maintain open access to reproductive health care

Andis Robeznieks , Senior News Writer

New state laws banning abortion do not eliminate the need for evidence-based reproductive health care—as seen by the dramatic growth in patient volumes at one facility operating in a state where the procedure is still legal.

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“Pre-Dobbs, we saw about 3,500 abortion patients a year; post-Dobbs, it will be about 10,000,” said AMA member Colleen McNicholas, DO, referencing the U.S. Supreme Court case that has allowed states to outlaw abortion.

Dr. McNicholas is the chief medical officer for Planned Parenthood of the St. Louis Region and Southwest Missouri, and she took part in a panel discussion of the post-Dobbs reproductive health care landscape during the 2023 AMA State Advocacy Summit.

She and her colleagues correctly anticipated that Missouri would quickly move to ban abortions if the U.S. Supreme Court overturned Roe v. Wade.

Her organization scouted for locations across the Mississippi River and in 2019 opened a facility in Fairview Heights, Illinois, where abortion remains legal. Dr. McNicholas and her colleagues also anticipated that the facility would attract an influx of patients from all over the country—and from Southern states in particular—so they chose a spot that was near the interstate highway and the airport, and only a 15-minute drive from downtown St. Louis.

What Dr. McNicholas and her colleagues saw coming had indeed come to pass, resulting in wait times growing from two days to almost three weeks.

“We've increased hours—we now offer care six days. We launched a new mobile abortion unit, we provide telemedicine abortion,” Dr. McNicholas said. “Despite all of those things, we have not been able to make any impact on the wait time.”

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Missouri has one of the strictest anti-abortion laws on the books, according to the Guttmacher Institute, and is only allowed in cases of where the mother’s life is endangered or their health is severely compromised.

Missouri is one of a handful of states that passed a “trigger ban” before the Dobbs v. Jackson Women’s Health Care Organization (PDF) decision and was designed to take effect as soon as Roe v. Wade was overturned. Missouri was the first state following the decision to invoke this ban.

Abortion in the U.S. is now governed by a patchwork of state laws, including:

  • Thirteen states with a near total ban.
  • One state, Georgia, bans abortion after six weeks.
  • Eleven states have bans that start between 15 and 22 weeks—all but two of these have more restrictive bans that have been enjoined by the courts.

“The decision by the U.S. Supreme Court in Dobbs v. Jackson Women’s Health Organization places physicians in an impossible situation: trying to fulfill their ethical duty to place patient health and well-being above all other considerations, while attempting to comply with vague, restrictive and conflicting state laws that intrude upon the patient-physician relationship and jeopardize patient health,” AMA President Jack Resneck Jr., MD, wrote in an AMA Leadership Viewpoints column.

AMA policy supports patients’ access to the full spectrum of reproductive healthcare options, including abortion and contraception, as a right,” Dr. Resneck added. “Our ethical obligation is to help patients choose the optimal course of treatment, through shared decision-making that is fully informed by evidence-based medical science and shaped by patient autonomy.”

Dr. McNicholas said that one of the most important things organized medicine can do is to “continue to normalize abortion as health care.”

“I cannot say how important I think that is,” she added.

Dr. McNicholas describes the 18,000-square-foot Fairview Heights facility as having a typical physician’s office feel, with the back half being an ambulatory surgical center with three operating rooms and a full recovery room.

In addition, a space formerly used for counseling has been turned into a “family room” with a chalkboard, changing table, and toys.

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“Patients were telling us: Look, if I could just bring my kid, then that would solve a bunch of problems,” Dr. McNicholas said.

A patient Dr. McNicholas cared for earlier this year “flew in with her husband and her child from Texas,” she noted. “Her husband and the kid stayed in the family room while she had completion of her care.”

To help avoid burnout, the staff schedule has gone from eight hours a day, five days a week, to 10 hours a day, four days a week to add another day of recovery.

Dr. McNichols said she and her staff get asked all the time, “How are you still in this fight?” And she said “the immense gratitude, the tears of relief” from patients reminds them of their work’s value.

That said, some days can be rough—especially days when their patients are preteen girls.

“We have always seen very young people, we have always seen victims of assault,” Dr. McNicholas said, but now—with patients coming in from several other states—the volume is higher than ever. To aid in one girl’s recovery, they held a birthday party for her after the procedure.

“Even our hardest days, even those days when we’re having birthday parties for 11-year-olds after their abortion, there’s a constant reminder of just how important it is that we are there,” she said.