When an Alabama clinic’s only OB-GYN left the state to provide abortion care in Colorado, the head of operations thought the facility would have to close. 

But Robin Marty, executive director at WAWC Healthcare in Tuscaloosa, hired a doctor in August who she called a “unicorn” — someone who’s from Alabama and, after training outside of the state, returned home to practice medicine. 

Marty said Alabama’s near-total abortion ban could cause physicians to practice elsewhere after they finish their residencies. 

“Doctors don’t want to worry about surveillance, potential arrests and other legal issues,” she said. 

A study published this month found that applications to medical residency programs in states with abortion restrictions have declined compared to states where abortion remained mostly legal. The findings are an “early signal” that the U.S. Supreme Court’s decision nearly four years ago overturning federal abortion rights protections may exacerbate health care shortages, said lead author Dr. Anisha Ganguly.

A majority of doctors end up practicing medicine in states where they trained. Obstetrician and gynecology training programs typically take four years to complete, so the full scope of how abortion restrictions affect where physicians work after they complete their residencies remains to be seen. 

Still, experts said the findings could spell trouble for the future of the reproductive health care workforce in states with abortion restrictions, some of which are already plagued with maternity care deserts. 

Doctors say bans limit training, standards of care

OB-GYNs affiliated with Physicians for Reproductive Health who either trained or work in states with abortion bans told States Newsroom that restrictions after the Supreme Court decision hamstrung their ability to offer reproductive care and affected the education of medical residents. 

Dr. Neha Ali grew up in Texas and trained there, too. But by the end of her OB-GYN residency’s second year, the state enacted SB 8, a six-week abortion ban that allowed residents in the state to sue providers or anyone who helped someone terminate a pregnancy. After the Dobbs decision in June 2022, a near-total abortion ban took effect in Texas.

“I knew I wanted to be an abortion provider before I started OB-GYN residency, and I chose to be in Texas for my residency training because I wanted to experience what that’s like in a state with barriers. But ultimately, the barriers became too large,” Ali said. 

After she finished residency in 2024, Ali moved to Colorado, a state with strong abortion-rights protections, where she practices complex family planning.

Ali said she talks to medical students about her experience training in Texas, where she was not able to perform any dilation and evacuations — a second-trimester abortion procedure — during residency. 

“I do think it’s very valuable to see what it’s like to be in a restrictive state and understand what that is like to be a provider there, but that doesn’t sell people on a residency for four years,” she said.

OB-GYN Dr. Louis Monnig trained in Kentucky before the state banned abortion. 

“Making it difficult or putting up barriers to that training just limits the abilities of any doctor who provides reproductive care to have opportunities to get exposure and experience, and just get better at what they’re doing,” he said. 

Monnig completed his residency in June 2023 and moved back to his home state of Louisiana because of his connections to the region and its health care disparities. “It felt like it was worth it to come back,” he said. 

In October 2024, a Louisiana law classifying mifepristone and misoprostol as controlled dangerous substances took effect. 

“It made me lose faith that lawmakers were doing any of these things to actually protect patients or patient safety,” he said. 

The medications are used not only for abortions, but miscarriages and other conditions, too. The law has sowed confusion among health care providers and led some to practice emergency drills to access the drugs during obstetric emergencies, Louisiana Illuminator reported. Monnig said the law has “changed some of the day-to-day operational workflow for patient care,” especially for situations where misoprostol is used, such as labor induction and postpartum hemorrhaging. 

Patients have faced issues when trying to get prescriptions filled: Pharmacists have called Monnig’s office to make sure a patient wasn’t having an abortion after he prescribed misoprostol for conditions such as cervical stenosis — when it’s difficult to insert a medical instrument in the cervical canal.

Drop in applications to ban states’ residency programs

Out of more than 22 million applications to 4,315 residency programs across the U.S., 67% were submitted to programs in states without abortion restrictions between 2018 and 2023, the new research showed. Thirty-three percent went to programs in states with restrictions. 

Fewer women than men applied to train in states with abortion restrictions before the Supreme Court’s landmark abortion ruling, according to the study, and that disparity widened after more than a dozen states enacted abortion bans. The number of men applying to residency programs in states with abortion restrictions — mostly in the South and the Midwest — also decreased significantly. 

“When there’s a decreased level of interest in these states, it suggests to us that there’s an evolving health care workforce shortage in these states,” said Ganguly, an internal medicine physician and an assistant professor at University of North Carolina’s Division of General Medicine and Epidemiology. 

Many states with abortion bans — Idaho, Iowa, Georgia and Missouri, for example — are also facing labor and delivery unit closures, particularly in rural areas where hospitals struggle with provider recruitment. Health officials in these states listed improvements to maternal health as a priority in their applications to the federal Rural Health Care Transformation Program, but solutions will take years to implement. 

Shortages affect more than one specialty. Ganguly said OB-GYNs have historically offered the bulk of abortion-related care in the U.S., but it’s increasingly important in emergency medicine, family medicine and internal medicine. Primary care providers and emergency medicine doctors often diagnose pregnancy complications such as miscarriages, and internists help women who have chronic disease manage and plan for pregnancy. 

Dr. Hector Chapa, an OB-GYN who teaches obstetrics and gynecology at Texas A&M University and is a member of the American Association of Pro–Life Obstetricians and Gynecologists, took issue with the study’s approach. 

“It’s essential to understand that this study is not specific to OB‑GYN residency programs, and by grouping OB‑GYN with family medicine, internal medicine and emergency medicine, the study assumes that all specialties are affected equally, despite their very different levels of involvement in abortion. This broad grouping risks introducing bias into the results,” he said in a statement. 

Ganguly said her team did examine applications to OB-GYN residency programs in isolation to affirm findings of a decline among applicants in abortion-restricted states. Looking at other specialties, too, was meant to provide clarity about how bans affect the health care workforce more broadly.

OB-GYN education and the maternal health care workforce 

The latest study adds to a body of research examining how the Supreme Court’s decision on abortion in 2022 affected training after medical school, particularly for those specializing in reproductive health care. 

In the 2023-2024 application cycle, the number of applicants to training programs in states with abortion bans decreased by 4.2% compared to the previous cycle, while there was less than a 1% decrease in applications to residency programs in states where abortion is legal, according to the American Association of Medical Colleges. 

In some states, abortion bans have definitively led to an exodus of OB-GYNs and maternal fetal medicine specialists. Idaho lost 35% of its doctors who provide obstetrics between August 2022 and December 2024, according to a study published in July. 

Having reproductive health providers flee states with abortion bans is “devastating,” according to Pamela Merritt, the executive director of Medical Students for Choice. 

“It’s a public health disaster that we’re going to see the consequences of decades to come,” she said. 

Merritt’s organization has chapters at several medical schools in states with abortion bans. She said students are not getting adequate training, and some are even discouraged from discussing abortion. 

In February, Texas Tech University Health Sciences Center canceled a Medical Students for Choice chapter’s talk with an OB-GYN who wrote a book about providing abortion care later in pregnancy. School officials told The Texas Tribune hosting the event on campus was not in the university’s best interests.   

“Everybody who graduates from medical school in Texas should know that there’s this thing called third-trimester abortion, that when the life of the mother is at risk, you legally can provide this care,” Merritt said. 

Republican Gov. Greg Abbott signed legislation last year clarifying that doctors can offer pregnant women abortions during medical emergencies. The Texas Medical Board released guidelines for the abortion law this year, nearly half a decade after the state banned most abortions and at least four Texans died after being denied prompt abortion care, ProPublica reported. 

Program helps residents in restrictive states get abortion care training 

“Every single physician, nurse and health care provider needs to be educated about abortion care,” said Dr. Jody Steinauer, an OB-GYN and the director of the Bixby Center for Global Reproductive Health at the University of Southern California in San Francisco. “This is a huge crisis in OB-GYN specifically: All OB-GYNs must have the competence and the skill to safely empty the uterus. Even if the individual is personally uncomfortable providing abortion care, they have to be able to empty the uterus to save someone’s life in an emergency.”

Steinauer leads the Ryan Residency Training Program, which works with OB-GYN residencies across the country to ensure comprehensive abortion and family planning rotations. Nearly a dozen states lack Ryan programs, and most of them have near-total abortion bans. 

She said residencies in states with abortion bans are struggling to make sure their students have the skills to provide abortion: “We’re at risk of having a whole generation of OB-GYN graduates who are not skilled to provide the care they need to provide.” 

To remedy this issue, the Ryan Program has helped to establish 20 partnerships with schools in abortion-restrictive states to train OB-GYN medical residents in states with reproductive rights protections. 

Steinauer said the rotations are between two to four weeks and complicated to plan, but they help doctors learn procedural skills, how to manage medication abortions and counseling. 

The rotations also help OB-GYNs navigate pain management during obstetric procedures, communicate effectively with abortion patients and familiarize themselves with ultrasounds, she said. These skills are important for providing the full spectrum of reproductive health care, from inserting IUDs to treating miscarriages, the doctor said. 

“It’s such a refreshing experience for them to be working in a state without a ban, and they get to see abortion as normal health care,” she said.