It’s been more than a year since the Supreme Court overturned Roe v. Wade, effectively ending the right to abortion, which had existed for nearly 50 years. The decision has led to a wave of laws to restrict abortion access in about half the states in the nation. Not only have patients had to cross state lines to end pregnancies which pose a risk to their health, some doctors have also fled states like Idaho where performing abortions could result in imprisonment.
Dr. Stella Dantas is an obstetrician and gynecologist in Hillsboro, and the president-elect of the American College of Obstetricians and Gynecologists. She joins us to explain the ripple effect that restricting abortion access is having on reproductive healthcare, especially for underserved communities.
This transcript was created by a computer and edited by a volunteer.
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. It’s been more than a year since the U.S. Supreme Court overturned Roe v. Wade, effectively ending the constitutional right to abortion that had been in place for nearly 50 years. The decision has led to a wave of laws that restrict abortion access in about half of U.S. states. Some patients have had to cross state lines to end pregnancies that pose a risk to their health. And some doctors from states like Idaho, where performing abortions could result in imprisonment, have moved. Needless to say, it’s been a tumultuous time for medical practitioners.
The most prominent professional group of OB-GYNs is called the American College of Obstetricians and Gynecologists or ACOG. It just so happens that the incoming leader of the group is an Oregon doctor. Stella Dantas is an obstetrician and gynecologist in Hillsboro. She joins us now to talk about her profession post-Dobbs and more broadly. Welcome to the show.
Dr. Stella Dantas: Thank you so much for having me.
Miller: And I should note for full disclosure for listeners that we’ve invited you because you’re the president elect of ACOG, but you happen to have delivered my children. So thank you for that.
Dantas: Thanks, my pleasure.
Miller: I understand that you found out that you had been selected as the next president, the incoming president, this coming May of this professional organization the day before the Dobbs decision overturning Roe v. Wade. Can you tell us about what those two days were like for you?
Dantas: So it was actually the day after. The Dobbs decision fell on June 24th of 2022. I actually happened to be in Washington D.C, visiting colleges with my son and so when that decision fell, we actually went to the Supreme Court. I wanted my son to see and experience history happening. And then the next day, I did get a call that I had received the nomination as President-elect. It was a surreal 48 hours.
That week before, I think we were all preparing for this decision. I’d been preparing statements for the people I lead and that at that time, it was the district part of the west coast and of what we were going to say, what we were going to be doing after and if the decision fell, but nothing prepares you for a day like that. It was heartbreaking, truly heartbreaking.
Miller: How has the Dobbs decision affected the way you’re thinking about your tenure that’s coming up as the president of ACOG?
Dantas: Well, so it’s a long game. My president tenure will be a year and the effects of this decision will go on for decades, unfortunately - is what I think. Optimistically, I wish it would not. Of course, we will be working on trying to achieve full access to reproductive healthcare for every person in this country. And we want to protect from legislative interference. So that will be a heavy amount of work that I will be doing during my presidency.
I will also want to mention that I will be focusing also on burnout and what is happening to our specialty. Coming out of a pandemic, we have burnout and just the amount of burden right now to practice medicine and this is just the tip of the iceberg here with legislation coming in, telling us how to practice. You’re seeing a patient and you’re not allowed to give them the full menu of options that is evidence based for them to make decisions about their health care. It’s really hard for our patients and it’s also hard for the providers, the clinicians, who are taking care of them.
Miller: A few months ago, researchers at the University of California-San Francisco, put out a study based on reports from OB-GYNs across the country. The title says a lot. This is the title: “Care Post Roe: Documenting cases of poor quality care since the Dobbs decision.” Can you give us a sense for some of the issues that came up in those cases reported by your colleagues?
Dantas: Yeah. Well, so some of it is delays of care. If you’re practicing in a state where you can’t provide an abortion in a timely manner. So you’re seeing delays of care. You’re seeing patients who have medical comorbidities, they have reasons where carrying a pregnancy would be deleterious to their health. They are having to travel long distances. Your counseling is affected. Our clinicians are scared of criminalization. They’re scared of going to jail. They’re having to balance how do I talk to my patients? How do I give them all the options without harming or putting risk to my family and myself?
So those are the stories, and then also just the fact that they have to travel. So we’ve got people in states who don’t have access to care they should so they’re having to travel miles and miles. Now some people have the means to do that. Many people don’t. So it’s affecting marginalized populations more and that’s very challenging and regrettable.
Miller: Just to be clear, with a lot of these cases, they point out that we’re not simply talking about people seeking abortion, we’re talking about the serious repercussions for say, somebody who is miscarrying. How might that work?
Dantas: So if somebody has a miscarriage and they need care–let’s say that they’re miscarrying in their second trimester–if there is not a provider around to take care of them, to help them if they are bleeding, if there is a patient with an ectopic pregnancy, and you’re in a state where that is considered illegal to take care of them until that patient is in a life threatening circumstance, the amount of trauma for that patient to have to wait to be cared for, to have their ectopic pregnancy to be taken care of until they’re in a life threatening circumstance, as opposed to upstream, and the amount of complications that that can arise and then the stress and toll for their clinician…so those are the types of stories that we’re hearing.
Miller: The New York Times had an article recently, and other outlets have done this as well, about OB-GYNs who’ve left states where abortion is being outlawed. You were actually quoted in that article. How common is this right now?
Dantas: So we are seeing a lot of shifts of providers in certain states that would be called our red states. So for example, I personally know a couple OB-GYNs who wanted to raise their family in a rural state. They intentionally went to Idaho to practice and as the climate became untenable for them, as they were worrying again, they have young children, they can’t be in jail for providing good care, they had to consider leaving. And so these clinicians are leaving for places [where] [they] have access. They’re coming to places like Oregon and unfortunately, we’re leaving even more maternity care deserts out there.
Miller: What are the implications of that? I’m also curious, obviously without naming names, what you’ve heard from clinicians across the country who have made that decision. They were practicing in places that they chose. They didn’t want to leave, they felt they had to.
What have you heard from them?
Dantas: Well, again, it’s the stress of the day-to-day and the emotions. As a clinician, you go into medicine to take care of patients and you develop these relationships with patients and you know you are not providing evidence-based optimal care for them, you can’t. That’s a hard burden to shoulder.
They are also worried again that they don’t want their kids to grow up without a mom or a father. And then also just thinking about communities. They don’t want to leave their communities and now we’re pulling people out of these communities.
And so in that article, I talked about a ripple effect and there’s not only a ripple effect to the care that people aren’t getting, there’s a ripple effect as to what we’re doing to these communities. We’re not just pulling out OB-GYNs, we’re pulling out partners and other people. We’re pulling out people that would be helping out at schools, other people in the community, ER physicians in the community. And it’s hard because they don’t want to leave. They don’t want to do that to the people they’ve cared for years, but ultimately, they have to make a decision that works best for them and their family.
Miller: Oregon does not have abortion restrictions of the kind that we’re talking about - really any - but we have seen a different trend over the last year or so. The planned closures of stand-alone birthing centers, one in Baker City, one in Gresham that happened and then the state didn’t have investigation said no Legacy, open it back up. But it made me wonder if this is a national trend, the closure of stand-alone centers.
Dantas: Yes. We are seeing this in a number of states all across the country. So about 35% of counties are considered, as of 2022, maternity care deserts, meaning they have no obstetricians, they don’t have care available. That number I would imagine is higher now, as we go toward the end of 2023. We are seeing birth centers close for a number of reasons, some of it may be financial, some of it maybe because they don’t have enough providers to staff and then they close. And what that’s doing now to our patients in those places, it’s not only making it hard for them to find a place to deliver. They might have to travel 75 more miles to find a birth center or a labor and delivery unit at a hospital, but it’s also affecting the care they get upstream.
Miller: Last week, we talked about the country’s terrible maternal and infant mortality rates. They’re among the worst among industrialized rich countries, despite the fact that we spend a lot of money as a whole in this country on healthcare. And there’s a lot to this. But in the big picture first, what stands out to you in these numbers?
Dantas: Well, in these numbers, what stands out to me is that here we are in a country where we have great care that should be available to all and it’s not; it’s only accessible to a few and the number is going down. And what I was talking about also is as we have these maternity care deserts, we are not making it easy for patients to get the care that we can provide in this country. So one barrier is just insurance coverage. But two again, if you have to travel, it’s not just for the birth, we’re not allowing people to get prenatal care so that they can optimize the health and their pregnancy to have a good outcome. And Dave you have kids. You know how many prenatal appointments there are. If you have to travel 75 miles to get care every time you go for a prenatal appointment, it’s hard. People are working, they’re taking time out of their schedules. If you just have to go 15 minutes to get care, it’s challenging to fit in. Imagine if you have to go an hour or more to get care.
Miller: From the perspective both as a clinician yourself and as the president-elect of the American College of Obstetricians and Gynecologists, how do you think about the gigantic racial disparities in those numbers, in particular among Black and African American mothers or mothers-to-be and Native American?
Dantas: Yes, the numbers are, unfortunately, much higher. The maternal mortality rate of a Black mother is three times higher than white women. It’s because of access to care and we are also doing a lot of work on diversity, equity and inclusivity at the college and around the country. We want to make sure that we have, one, patients and all populations have access to clinicians, and also, two, clinicians that they identify with. That’s extremely important, right? Because if I’m saying something to you as a patient and we’re not identifying with each other, it’s probably much harder for you to take what I’m saying and do it. It’s already hard to try to do things to improve your health. So, we are trying to work on that and improve the diversity of the clinicians that are around the country.
Miller: I should say we’re going to be talking more deeply about Multnomah County’s efforts to address some of these racial disparities in the next segment.
The Commonwealth Fund put out a big report about maternal mortality a few years ago and they had a really striking chart to me. It showed the maternal care workforce in 11 different rich countries. The U.S. has fewer providers overall than all of them except for Canada, but we also have a much lower ratio of midwives to MDs, to OB-GYNs, than almost all of them. This might be sensitive because you represent OB-GYNs. I’m curious if you would support increasing the rate of the use of midwives, nurse midwives or whatever, for uncomplicated pregnancies in this country. I mean, should people like you be delivering fewer babies in the U.S.?
Dantas: Yes. I’m happy to comment on that. The American College of OB-GYN has a great relationship with the ACNM…
Miller: Which is?
Dantas: The American College of Nurse Midwives. And you may know that I have a collaborative practice with certified nurse midwives where I work. I am very supportive of having a diverse workforce and everyone working to the top of scope. Yes, we are looking at a physician shortage. And again, I was talking to you about my concern about the burnout. I think one way to help keep people in the workforce is to make sure we are all working to top a scope, finding joy in what we do and also that we have enough people to do the work so no one is overly burdened to burn out. So, yes at ACOG we support team-based care and certified nurse midwives, they provide great low risk care and they work collaboratively with obstetricians and gynecologists so that when things do turn high risk, we can be there to help and support.
Miller: The cesarean rate in the U.S. is something like 33%. One in three pregnancies are through C-section. That can increase morbidity and mortality for mothers, particularly in subsequent deliveries. What do you think it would take to reduce that rate?
Dantas: So, one thing that would be helpful is just reducing the primary cesarean section rate.
Miller: Meaning for the first birth?
Dantas: Right. For the first birth. And so there has been a lot of work done. In fact, the college has a program called the Alliance for Innovation on Maternal Health. It’s called AIM. It has bundles that are being released nationally and they work in conjunction with state hospitals all around the country and one of those bundles is proven to prevent the first cesarean. So it is about making sure that we have the right personnel available, that we are watching people as they labor and giving them all the opportunities that we can so that they can have a successful and safe birth vaginally.
Of course, there are times when you have to do a cesarean section for the safety of the mother, for the safety of the child, but just trying to make sure that we are practicing to the right standard all across and that we have facilities available to care. Sometimes people need rest, they may need an epidural, they may need that to get through the rest of their labor to help their body relax and move forward. So there’s a lot that we are doing.
Miller: Are you advocating for any changes in training in residency to make this more possible? I mean, I’m thinking, for example, about giving OB-GYNs to-be more experienced with vaginal deliveries for breech presentations where the baby is, right side up, meaning the wrong way.
Dantas: Right. Well, as you may know with singleton breech deliveries, data came out that they were unsafe, but certainly there are patients that choose, even with the data, they want to have a singleton breech vaginal delivery meaning one baby delivering breech. And there are a smaller number of people that know how to do that in this country. I do advocate for an interdisciplinary training environment. We do this here where I practice. We have residents and medical students training and seeing how certified nurse midwives and OB-GYNs work together to provide informed care and support patients’ choice in a safe way.
And so yes, we need to have training so that we can support all of patients’ choices and work together upstream so that when we get out–and wherever we practice around the country because the cultures are different–that we are working together.
Miller: Well, Stella Dantas, thanks very much.
Dantas: Thank you.
Miller: Stella Dantas is the president-elect of the American College of Obstetricians and Gynecologists. She is an OB-GYN herself, practicing in Hillsboro.
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