Why some doctors stay in US states with restrictive abortion laws and others leave

Many maternal care doctors in states that have restrictive abortion laws are facing the choice of whether to stay or leave after last year's Supreme Court decision that overturned Roe v. Wade

Dr. Kylie Cooper chokes up thinking about the patients she left behind in Idaho.

One who often comes to mind is Kayla Smith.

Smith said she chose to end a desperately wanted pregnancy last year after discovering her fetus had potentially deadly heart defects and other problems. But Idaho banned nearly all abortions after the U.S. Supreme Court overturned Roe v. Wade in June, so Smith had to go to Washington state. Cooper felt “deeply saddened” she couldn’t care for her the way she normally would have.

And this is one of the reasons Cooper, a maternal-fetal specialist, moved in April to Minnesota, which has broad abortion rights.

“Obviously it was a very difficult decision for me and my family," she said. But they needed to be “where we felt that reproductive health care was protected and safe.”

Post-Roe, many maternal care doctors in restrictive states face the same stark choice: Stay or go? They must weigh tough questions about medical ethics, their own families and whether they can provide the best care without risking their careers or even winding up in prison. They know a lot is at stake for patients, too, due to current and projected widespread maternal care shortages in the U.S.

Some doctors make a different choice than Cooper. OB-GYN Dr. Alecia Fields moved back to her native Kentucky around the time news first leaked about the Supreme Court’s ruling. She practices in a conservative rural county and can no longer provide abortions part-time in Louisville like she once did.

Fields feels an intense connection to her state and hopes to foster change from within. Plus, she said, “there's a big need for providers in general in terms of reproductive health care.”

Nationally, 44% of counties had low or no access to obstetric providers, according to a 2022 March of Dimes report based on data gathered before the Supreme Court ruling. That figures jump to more than 50% in Kentucky, Idaho and some other states with restrictive abortion laws.

Federal projections show a widening gulf between supply and demand for OB-GYNs nationally through 2035. And among the 24 states that have taken steps to restrict abortion, all but Ohio will see an even bigger need by then, according to The Associated Press' analysis of the federal data.

Abortion restrictions, combined with the challenges of practicing in rural areas, threaten to expand so-called “maternal care deserts," said Dr. Amy Domeyer-Klenske, who chairs the Wisconsin section of the American College of Obstetricians and Gynecologists.

This won't just affect people seeking abortions, said McKay Cunningham, who teaches reproductive rights and constitutional law at the College of Idaho. “It has ramifications that really just affect every woman, every family, that wants to have children.”

STAYING IN KENTUCKY

As the midday sun glistened on Lake Cumberland, Fields knelt down to feed her backyard chickens. She and her husband, who is a stay-at-home dad, bought a house and barn on three acres to raise their two little boys.

That’s how Fields, 36, grew up — shuttling from her parents’ house in Lexington to her grandparents’ house in the country. “You could just run and go anywhere and play anywhere,” she said. “Everybody kind of knew each other, came over for Sunday dinners and it just had a real warm feeling to it.”

At the University of Kentucky and later in medical school, Fields became an advocate for reproductive rights. She served on the board of Medical Students for Choice and learned abortion care during her residency in Rochester, New York. When she worked at a health center in Indianapolis, she drove to Louisville monthly to provide abortions at Planned Parenthood.

Then last spring, she got a job offer from a health center in Somerset, Kentucky. It was a chance to serve a county where nearly 1 in 5 people live in poverty and some drive an hour or two for care.

But Fields said the abortion decision leak brought up “a lot of fears” and made her wonder: “What is this going to mean on the ground? Am I going to be criminalized?”

She decided to risk it.

Now, she tries to provide the best care possible given the limitations. She said her goal is to “create a really safe space that’s very open-ended,” where patients can share whether their pregnancies are planned, how they feel about them and what they want to do. If necessary, she can point them toward information on out-of-state abortion providers and travel funds. She can also prescribe birth control and offer permanent sterilization — something more of her patients are seeking.

And if an emergency puts a mother’s life in danger, abortion is allowed. “The hard thing is, waiting until that moment puts the patient at a lot of risk,” Fields said.

Despite constraints on her practice, patients regularly thank Fields at the clinic or when she bumps into them at Walmart. One expressed her gratitude publicly on Facebook, describing how she hemorrhaged while delivering her baby — and Fields saved them both.

Fields displays her love for Kentucky on her dining room shelves, where she's placed a wooden cutout and colorful picture in the shape of the state, a horse statue and the framed saying “home sweet home.” She envisions staying for a long time and caring for generations of local families.

“I want to be settled,” she said. “To kind of put down roots and build on them.”

LEAVING IDAHO

Cooper, like Fields, wanted to practice where she was needed and “make a huge impact."

She moved to Boise in 2018, and the job proved extremely rewarding. She handled the toughest cases, shepherding some women through loss and helping others welcome healthy babies despite serious pregnancy complications. She made deep connections with patients, families and coworkers.

Her family loved Idaho. She and her husband, also a stay-at-home dad, lived in a great neighborhood and had a group of friends. The kids, 9 and 6, did well in school.

“We just had a good life,” Cooper, 39, said. “We had no plans to leave.”

That changed after Idaho banned abortion. Under state law, doctors who perform the procedure can be charged with a felony and have their medical license revoked.

For some of Cooper’s patients, abortion was the best option and the only way to preserve life and health.

“The idea of not being able to help them the way that I should was just was terrifying,” she said.

She was already having to run some cases by hospital attorneys and feared she might soon be forced to choose between her patients’ welfare and her own. If she went to prison, she realized, her children might go years without a mom. And the family’s income would disappear.

All she and her husband would talk about, she said, “was abortion care and my job and just all the stress of it.”

A new poll by KFF, a nonprofit that does health care research, found 61% of OB-GYNs in states with abortion bans say they are very or somewhat concerned about their own legal risk when making decisions about patient care and whether abortions are necessary.

One of Cooper's colleagues in Idaho also decided to leave, surveyed other maternal care professionals and found dozens more were considering moving out of the state within the next year.

Cooper's family is now settling into a new house in Minnesota. They're still unpacking. They’re figuring out new schedules and looking for new friends. “Basically,” Cooper said, “we’re trying to find what we had in Idaho.”

She said she still worries a lot about her former patients, over which "lots of tears were shed and still are.”

Smith misses Cooper just as much. The doctor cried with her when she chose to end her second pregnancy after realizing halfway through that her fetus likely wouldn’t live. And Cooper helped her cope with the loss of baby Brooks, who lived a few moments after induced labor.

When Smith learned Cooper was leaving, she stopped by her office to thank her for everything and give her flowers and a hug.

“I’m just really sad. She was so kind. She changed our lives,” said Smith, who is also considering moving away. “I don’t blame her for leaving. But it sucks for everyone here.”

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