46 Comments

What I’m NOT seeing in the aftermath of Dobbs is an increasing emphasis on pregnancy PREVENTION - which is still almost solely women’s burden. It is long past time for a shift to equalizing that burden, especially now that, with abortion off the table, many tens of thousands of men will now find themselves to be unwitting and unwilling fathers of living children that they will now have the burden to support and provide for. It is time - long past time - for men to be organizing and agitating for safe, effective, reliable measures that prevent them from unwillingly and unwittingly becoming lifelong parents. The male reproductive and hormonal system is so much less complex than that of women. Birth control for men that blocks the production of sperm should be a research priority - and millions of men should be in the streets agitating for it - for themselves, for their wives, for their sisters, for their daughters, for their sons and brothers.

And for those who will inevitably respond that “men can’t be trusted to protect themselves and their sexual partners, or to tell the truth about it, ” I say, “Honey, what’re you doing sleeping with someone you can’t trust??”

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there has also been a movement of established, board certified, OB-GYNs out of states with restrictive abortion laws into states without such laws. this has exacerbated already poor access to obstetric care - not to mention women's health care in general - in states such as Idaho, where I live, in which there have been high profile, well-publicized instances of established OB-GYNs moving out of state as a direct result of restrictive abortion laws. not surprisingly, this has also made it exceptionally difficult to recruit new OB-GYN physicians to the state. it would be interesting to see this quantified nationally.

this has obvious adverse implications to women's health. i realize abortion is a challenging and nuanced issue, but once again the bottom line hypocrisy of right wing politicians and judges who purport to be pro-life is on display by the extreme laws they enact and the decisions they make, of which Dobbs is only one example. and, as others have pointed out, this disproportionately harms women who are not affluent enough to travel out of state for care.

surely there must be a more humane way to approach this issue than the system we have now.

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Dr. Uhlmann,

Thank you for your comment. In a rational world, bodily autonomy for women and girls would be recognized as a human right protected by the constitution and not subject to control by legislatures or courts. Pregnancy is too complex to be legislated. If all restrictions on abortion were to be removed, I predict that second and third trimester procedures would likely only be done in cases of fetal anomaly or pregnancy-related maternal medical conditions.

Karen Herman, CNM (Retired)

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Nailed it.."Pregnancy is too complex to be legislated."

After seeing proposed or past bills legislating impossible medical procedure, it's quite clear they have no clue. Take the Ohio proposed bill to have ectopic pregnancy can be taken from where it implanted and re-implanted in the uterus.

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obstetrical care needs to be regulated at multiple levels for multiple reasons. i find this statement odd; an anarchic approach to pregnancy care would seem guaranteed for problems in many ways. i can't support elective abortion due to my agnostic secular humanism. i think all human individuals with capacity for development have rights, recognized or not. regulations and laws are not only required to balance these conflicting rights; even disregarding the human rights of unborn humans, we have experience with unregulated medical care which suggests it permits bad outcomes.

an international agreement on the human rights of unborn humans is needed, given the progress in genetic engineering, artificial womb technology etc.

i agree that bodily autonomy is a human right. this is one of the reasons for regulation, to balance the human rights of the mother and the human rights of the child.

i think if all restrictions were to be removed, there would be rare terminations of near-term and term pregnancies. perhaps very few, but some. we've seen it with medications under current regulations as late as 32 weeks.

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Dr. Zorn,

I would appreciate any documentation you have for late term pregnancy terminations which were NOT done for reasons of severe fetal anomaly or serious maternal health problems.

Thank you

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i don't have any data, here's a doubly tragic case. i wonder if the availability of medication abortions has increased the incidence of this sort of event. https://www.cnn.com/2023/06/12/uk/woman-jailed-abortion-pill-intl-gbr/index.html

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Thank you for the link to the CNN article. I had not heard about that case.

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I believe I have seen some figures mentioned in either NEJM or JAMA but cannot recall which one. Also, apparently having impact on med students shying away from this specialties. adding to the shortage. https://www.nbcnews.com/nightly-news/video/ob-gyn-shortage-worsening-in-u-s-one-year-after-roe-v-wade-reversal-184186949952

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founding

The law was not really about abortion, it was about women's freedom and who should make personal decisions a woman or a congressman? It's all about control of women and they use some religious stuff to back up their quest to control. Birth control is next.

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i think this is a series of fallacious arguments, stephen. even if all critics of elective abortion are as evil as this trope attempts to cast them, straw or ad hominem arguments don't address the core question at hand, of vestment of human rights; slippery slopes either. none of us get to make personal decisions to terminate other humans in my ethic, which has zip to do with oppression,misogyny etc.

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founding

Bill, I will not take the bait and argue about abortion. It is NOT about the ethics of abortion or your religious values or when life begins. Life doesn't begin, it is a continuum. The real question is about who gets to make decisions for others? You want to use religion (that has changed over time) to guide decisions for others. Use your religion anyway you wish, but that does not allow you to tell women that they have to approach death before a procedure is ok with you and your belief system or in some states, women will just die if they miscarry because doctors are threatened with prison for administering care. That is not pro life, that is forced values, your values, on others. This has 100% to do with control, oppression using your belief system as the core.

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thanks, stephen. i disagree that this is about who gets to make decisions for others, it's more fundamental than that; it's who gets to be called 'other', a person with human rights. that hurdle must be crossed before one can address things like whether a decision is in the best interest of both parties, or the conflict of rights between two patients. we agree life began long ago, but a new human individual is formed at fertilization, and if at that point they have the capacity for full development they have a future separate from other humans. i have no religion, so that argument is as misdirected. as an agnostic secular humanist, i see experience as paramount; taking that future is the major reason why killing any human is wrong in my humanism, separate from any suffering during the killing. direct your argument toward justification for intentionally stopping that future from continuing for a human individual, i'd be interested. fwiw i've read scripture, and see no jewish nor christian proscription against elective abortion; nor slavery, or genocide, not unexpected from a god who permits all known evils, at least. i support and have performed therapeutic abortions, so that argument likewise fails. i try to avoid newspeak, particularly in discussions on science, and try to avoid loaded terms like pro-life, choice, etc. in substantive discussion in favor of more accurate language. i don't think gop government gets much right and don't support them at all.

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founding

False. What is considered alive is your religious beliefs. Some say ovum and sperm are alive and must be protected. That is your religion not my beliefs. All religions or if you don't have any are belief based systems. You keep your religion out of my families life. If one of my daughters had an ectopic pregnancy and might die, I don't want to hear that there isn't a doctor that will save her life for fear of your religious persecution and prison. It is 100% about some people feeling they know what is right for others based on the current interpretation of a generationally altered text.

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you insist i operate from a religious motivation; i do not. to be honest, it sort of amazes me that the conservative right's religion is based upon what appears to my reading of scripture to be a gay communist. i object to elective abortion for the same reason i object to the intentional death of any human. obviously gametes are (and somatic cells) alive, but they are not human individuals with intrinsic rights separate from the larger organism of which they are a part, this is a confused, fallacious argument which i do not assert perhaps better addressed to 'some say'. i support and have performed therapeutic abortions. i too think care should be accessible. i'd prefer broad discretion for providers; some new laws use the 'belief of the provider' that an abortion is permitted.

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This analysis offers a stark contrast between the outcomes of theocratic decision-making and those of rational, data-driven decision-making.

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As a family doctor who has emphasized women's health in my practice and included prenatal care and delivery in my practice, I don't have hard numbers but can relate this much. The past few months I have received many recruiter texts, emails and voice mail messages seeking "FP with OB including C-section privileges." This is unprecedented in my experience.

Very few family doctors now provide obstetric services and those who do their own C-sections (rather than consulting an OB) are very rare, typically in very small towns with no OB-GYN on hospital staff. These requests are all coming from states with restrictive abortion laws, and I suspect they now cannot recruit OB-GYNs who will practice there, and OB-GYNs who were there have now closed their practices to leave the state, or have retired.

More than 90% of all abortions are already done in the first trimester and a majority are medical abortions, not surgical. In my experience, the occasional woman who is beyond the first trimester had irregular cycles and didn't recognize the pregnancy, or they had a delay due to gathering the finances to pay for a surgical procedure; those abortions were done early in the second trimester by 15 - 16 weeks. Of the thousands of pregnant women I've seen, all abortions (except one) done later than that were the result of fetal abnormalities detected by testing done in wanted pregnancies, or very rarely, for serious maternal illness that jeopardized the woman's life. The exception was a teen whose pregnancy was the result of rape, not diagnosed until 15 - 16 weeks, and whose family had to collect the much higher dollar amount for a late procedure, then travel to a distant city for it to be performed at 23 weeks.

I do not know, nor have I heard rumor via the grapevine, of any clinician performing an abortion that was illegal in their state. No practitioner wants to be the "test case" whose life and finances are unpended by prosecution for such a criminal offense.

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Adding that I don't see any clinic or hospitals wanting to be that "test case" as well.

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"..data suggest that most women seeking later terminations are not doing so for reasons of fetal anomaly or life endangerment."

https://onlinelibrary.wiley.com/doi/pdf/10.1363/4521013

the data seems pretty weak overall.

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From a brief scan of the article, a statement that "most women" seeking termination after 20 weeks are not doing so due to anomaly or health risk is not yet determined to be accurate. Many women do not find out about any fetal anomaly until after the anatomy scan ultrasound done at 18 to 20 weeks. If there is suspicion of anomaly, then a more formal scan, perhaps a genetics consult and consult risk with a maternal fetal medicine specialist would be done before any termination regarding management is made. This could well occur in the 20 - 24 week range.

Without more specific data on gestational age at termination, one can't state a specific reason that "most women" have a termination at or beyond 20 weeks. Some or many women do so because of delays, typically financial and transportation issues but we do not have a good grasp of those total numbers. My impression from my own practice is that few healthy women discover in the third trimester that they are pregnant and decide then to terminate their pregnancy. Even fewer doctors would perform such a procedure.

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i only have an abstract for the first reference to that statement; didn't see it in the second link. i wonder how much data we have on that, given the nature of these events, the legality etc.

i expect they're still pretty rare, but wonder if online medication abortion availability, maybe some other factors have affected the rate. i saw 4 cryptic pregnancies in my training and practice, i can see how this could happen.

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I am sure that such cases do occur and that is why there are physicians who will perform third trimester terminations under rare circumstances that can be considered medically indicated for maternal reasons. The details of the medical indications are as varied as the women themselves, which is why the decision should be made by the doctor and the patient, not external legislation created by those without adequate medical knowledge and training to do so.

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well, sure. when there are medical indications, that's the business of the physician to offer appropriate therapy. providers shouldn't be left hanging in the wind with these new laws, either, people need to know what's acceptable and what's not.

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Thank you for saying "when there are medical indications, that's the business of the physician to offer appropriate therapy." This is exactly why I think that ALL healthcare decisions (including reproductive healthcare) should be made by the patient and the physician, NOT legislators or judges.

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Thank you. This is another in your series of excellent columns.

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Thank you so much for this informative piece and for links to various safe ways to get abortions. It is terrifying to see this country actively become The Handmaids Tale. Thanks for contributing to the resistance with clear science.

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Thereby demonstrating that if the ONLY thing you want to do is ban abortion AND you can control enough State power to tell the majority to sod off AND you don't give a flip about the consequences to society as a whole by doing so, it's fairly easy to accomplish.

Less easy to accomplish: convincing anyone outside of your bubble that doing all this makes you Morally Superior and a Good Christian. Rather the opposite, in fact, on both counts.

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I still can’t wrap my ahead around how women, their health and their rights have been pushed back so far. The autonomy over our bodies that is a right was just stripped away. I am writing and voting accordingly, but in Texas it does not seem to make a dent in the perspective.

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Thanks so much for this (upsetting) information. I so appreciate your work. Would love your thougths on this column in yesterday's NYT: https://www.nytimes.com/2023/06/21/opinion/covid-lab-leak-origins.html

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I read the NYT article you cite a few days ago. The "Reader Comments" are spot on. It seems no matter where one falls on the political spectrum, most Americans have a low tolerance for censorship. Muzzling free speech is simply Un-American.

At the beginning of the pandemic, any mention of "virus lab leak" was quickly silenced. Even the newspapers censored themselves, which is truly disturbing, because a free working press is not just the hallmark of democracy, it's essential to a democracy's ability to function.

Here's what will be remembered from the pandemic: some misinformation was later proven to be true.

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"Increase in maternal mortality is likely". Glad to see that whole "pro life" thing is going so well. /s

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To repeat myself, here’s a law that needs to be passed.

“From the moment of conception, the sperm producer will be responsible for appropriate financial child care related support until the child is 18 years old or 22 years old under special circumstances.”

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i've read that this is part of the new georgia law, not sure about other states. i'm not sure 'the sperm producer' would be the way i'd describe it any more than referring to the mother as 'the incubator'; both are dehumanizing. an infertile man should still be responsible for any child he fathers, either personally or by proxy, and a mother who uses a surrogate as well.

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Good point, and surely in such cases of coping with infertility there would be emotional and financial engagement, not just hit and run impregnating.

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Beneath the data are hundred of stories of cruelty, confusion and lack of viable treatment. The HCWs are concerned about legality more than healthcare.

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This is a well written column with an important and powerful message. When you wrote about covid I could share these columns with my neighbors by sending a link but this no longer seems to be possible. I hope that I am wrong -- your column is too important to be hidden behind a paywall!

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Link should work - this article is not paywalled immediately. Likely only becomes paywalled after 30 days like the rest of her pieces. If you still have the email where this was sent you can indefinitely forward that too.

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thanks karen! great points! i agree wholeheartedly. it really is a human rights issue when you get right down to it, and that is a great way to frame the issue.

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