A beleaguered abortion workforce braces for things to get far worse

David Cohen and Carole Joffe, opinion contributors
·12 min read

In light of the recent Supreme Court decision on abortion, Dobbs v. Jackson Women’s Health Organization, abortion providers in states that have banned abortion, or soon will, are mourning the closing of their clinics. While they are concerned about their own and their colleagues’ future employment, they are even more deeply worried about the future reproductive health needs of the communities they have served for so long.

Meanwhile, abortion providers in states where abortion remains legal have worries of a different order. For these providers, the worry is that because abortion will remain legal in their state, they will likely receive a huge increase in patients traveling out of ban states in order to receive care.

In the past few months, we have interviewed providers in both states that were expected to ban abortion and those that are expected to receive patients from neighboring states. It is clear that the latter are concerned about the impact of the coming “tsunami,” as several have put it, on both their patients and their staff. They are preparing as best they can, but as one administrator told us with a sigh, scaling up to treat all who will request services once abortion is illegal in half the country is “unattainable.” Abortion clinics in the state of Illinois, for example, anticipate receiving up to thirty thousand additional out of state patients a year.

The considerable challenges facing abortion clinics in the states where abortion remains legal were already in evidence, even before the court’s decision was announced. These challenges started early in the COVID-19 pandemic, in the spring of 2020, when several states abruptly shut down abortion facilities for a period, claiming they were “non-essential” care. Then came the imposition of Texas’ Senate Bill 8 in September 2021, which banned abortions after roughly six weeks. Both of these events dramatically increased demands on clinic capacity in states neighboring the states that banned or severely restricted abortion. So many patients came from those states to the states where abortion remained legal that it created a domino effect of sorts. Clinics quickly became overbooked, with appointments often only available three or more weeks out, and travelers and local residents were forced to travel to yet other states for care, increasing similar pressure in those states.

SB8 and the pandemic-caused closings also, unsurprisingly, revealed the desperation of patients determined to get an abortion, no matter the obstacles. A clinic administrator in a state that saw a surge in people seeking abortions recalled one such memorable patient. The patient had driven 12 hours from Texas in a snowstorm. The patient’s mother apparently had just the day before been admitted to an Alzheimer unit and her daughter was uneasy about leaving her. The administrator told us the patient “had her mother and her mother’s caregiver in the car with her. And the patient was just like, ‘I got to take care of this woman and I got to have an abortion, all in the same day.’”

It bears mentioning that this round-trip drive of 24 hours (not counting the time at the clinic) in difficult conditions was to receive medication abortion. In other words, this patient drove for a day with her sick mother just to be handed some pills. In a sane world, these pills, which are safer than Tylenol, would be dispensed in her home town or received via mail right to her door. However, because of telehealth restrictions and abortion bans, this travel ordeal was the only possible solution for this patient.

Staff shortages and supply chain issues—issues that are familiar to so many through these pandemic years — are also a major concern and are expected to intensify, as clinics in states where abortion remains legal attempt to expand their capacity. One administrator expressed her frustration to us that adding a desperately needed additional procedure room for her clinic has been delayed because of the difficulty of getting a new exam table. But she told us that the greatest challenge she faces is hiring an adequate number of nurses and medical assistants, as the labor shortage appears to have hit this field particularly hard. A clinic director in another state who was facing a surge of patients and thus an increased need for employees spoke wistfully of the $5,000 signing bonuses that a major hospital in her area was offering nurses, an offer she was not able to match.

The difficulties in hiring additional staff predictably add to the stress and fatigue of current clinic staff. Several managers we spoke with raised concerns about the morale of their current employees because of the rising patient loads. In clinics that provide other reproductive health services in addition to abortion, the stress has been especially acute, as these services compete with abortion care for limited clinic capacity. As one administrator told us about her attempts to reassure her staff, “And what I have said to them, is that they’re now operating in a theater of war. It’s not their fault they’re not able to provide the care to all these people who are coming in with extraordinary circumstances, but they still take it to heart.” Her response is to “invest in our employees,” which in practical terms means mental health days, paid leaves, and “all the things you can imagine that people need to work in a good environment.” However, these are also things that require more staff to make up the time, compounding the personnel problems clinics are facing.

Some clinics with the resources to do so are strategically opening new facilities near the borders of states that will likely ban abortion after Dobbs is announced. But in this new environment of abortion care, older problems of abortion provision remain. Recounting for us a visit to a border town where her organization was considering opening a new clinic, an administrator casually mentioned that, in addition to an extensive set of meetings with local elected officials and health care workers, “I met with the FBI agent there, they have some bomb squads there.” After all, when abortion is banned in half the country, antiabortion extremists who have had to operate in 50 states will now be able to concentrate their efforts in just 25, making the conditions on the ground even more terrifying in the states where abortion remains legal.

All the challenges mentioned here for clinics operating in states where abortion remains legal will only intensify after the expected overturning of Roe. The abortion providing community will, as it has always done, make extraordinary efforts to meet the health care needs of those who come to them. We saw this happen with a good measure of success with Texas and SB8. But when two dozen states ban abortion after Dobbs, it very well might be impossible to amass a response on this scale. As a result, many pregnant people will inevitably not be able to be served.

David Cohen is a professor of law at Drexel University. Carole Joffe is a professor of obstetrics, gynecology and reproductive sciences, at the University of California, San Francisco.

A beleaguered abortion workforce braces for things to get far worse

David Cohen and Carole Joffe, opinion contributors

In light of the recent Supreme Court decision on abortion, Dobbs v. Jackson Women’s Health Organization, abortion providers in states that have banned abortion, or soon will, are mourning the closing of their clinics. While they are concerned about their own and their colleagues’ future employment, they are even more deeply worried about the future reproductive health needs of the communities they have served for so long.

Meanwhile, abortion providers in states where abortion remains legal have worries of a different order. For these providers, the worry is that because abortion will remain legal in their state, they will likely receive a huge increase in patients traveling out of ban states in order to receive care.

In the past few months, we have interviewed providers in both states that were expected to ban abortion and those that are expected to receive patients from neighboring states. It is clear that the latter are concerned about the impact of the coming “tsunami,” as several have put it, on both their patients and their staff. They are preparing as best they can, but as one administrator told us with a sigh, scaling up to treat all who will request services once abortion is illegal in half the country is “unattainable.” Abortion clinics in the state of Illinois, for example, anticipate receiving up to thirty thousand additional out of state patients a year.

The considerable challenges facing abortion clinics in the states where abortion remains legal were already in evidence, even before the court’s decision was announced. These challenges started early in the COVID-19 pandemic, in the spring of 2020, when several states abruptly shut down abortion facilities for a period, claiming they were “non-essential” care. Then came the imposition of Texas’ Senate Bill 8 in September 2021, which banned abortions after roughly six weeks. Both of these events dramatically increased demands on clinic capacity in states neighboring the states that banned or severely restricted abortion. So many patients came from those states to the states where abortion remained legal that it created a domino effect of sorts. Clinics quickly became overbooked, with appointments often only available three or more weeks out, and travelers and local residents were forced to travel to yet other states for care, increasing similar pressure in those states.

SB8 and the pandemic-caused closings also, unsurprisingly, revealed the desperation of patients determined to get an abortion, no matter the obstacles. A clinic administrator in a state that saw a surge in people seeking abortions recalled one such memorable patient. The patient had driven 12 hours from Texas in a snowstorm. The patient’s mother apparently had just the day before been admitted to an Alzheimer unit and her daughter was uneasy about leaving her. The administrator told us the patient “had her mother and her mother’s caregiver in the car with her. And the patient was just like, ‘I got to take care of this woman and I got to have an abortion, all in the same day.’”

It bears mentioning that this round-trip drive of 24 hours (not counting the time at the clinic) in difficult conditions was to receive medication abortion. In other words, this patient drove for a day with her sick mother just to be handed some pills. In a sane world, these pills, which are safer than Tylenol, would be dispensed in her home town or received via mail right to her door. However, because of telehealth restrictions and abortion bans, this travel ordeal was the only possible solution for this patient.

Staff shortages and supply chain issues—issues that are familiar to so many through these pandemic years — are also a major concern and are expected to intensify, as clinics in states where abortion remains legal attempt to expand their capacity. One administrator expressed her frustration to us that adding a desperately needed additional procedure room for her clinic has been delayed because of the difficulty of getting a new exam table. But she told us that the greatest challenge she faces is hiring an adequate number of nurses and medical assistants, as the labor shortage appears to have hit this field particularly hard. A clinic director in another state who was facing a surge of patients and thus an increased need for employees spoke wistfully of the $5,000 signing bonuses that a major hospital in her area was offering nurses, an offer she was not able to match.

The difficulties in hiring additional staff predictably add to the stress and fatigue of current clinic staff. Several managers we spoke with raised concerns about the morale of their current employees because of the rising patient loads. In clinics that provide other reproductive health services in addition to abortion, the stress has been especially acute, as these services compete with abortion care for limited clinic capacity. As one administrator told us about her attempts to reassure her staff, “And what I have said to them, is that they’re now operating in a theater of war. It’s not their fault they’re not able to provide the care to all these people who are coming in with extraordinary circumstances, but they still take it to heart.” Her response is to “invest in our employees,” which in practical terms means mental health days, paid leaves, and “all the things you can imagine that people need to work in a good environment.” However, these are also things that require more staff to make up the time, compounding the personnel problems clinics are facing.

Some clinics with the resources to do so are strategically opening new facilities near the borders of states that will likely ban abortion after Dobbs is announced. But in this new environment of abortion care, older problems of abortion provision remain. Recounting for us a visit to a border town where her organization was considering opening a new clinic, an administrator casually mentioned that, in addition to an extensive set of meetings with local elected officials and health care workers, “I met with the FBI agent there, they have some bomb squads there.” After all, when abortion is banned in half the country, antiabortion extremists who have had to operate in 50 states will now be able to concentrate their efforts in just 25, making the conditions on the ground even more terrifying in the states where abortion remains legal.

All the challenges mentioned here for clinics operating in states where abortion remains legal will only intensify after the expected overturning of Roe. The abortion providing community will, as it has always done, make extraordinary efforts to meet the health care needs of those who come to them. We saw this happen with a good measure of success with Texas and SB8. But when two dozen states ban abortion after Dobbs, it very well might be impossible to amass a response on this scale. As a result, many pregnant people will inevitably not be able to be served.

David Cohen is a professor of law at Drexel University. Carole Joffe is a professor of obstetrics, gynecology and reproductive sciences, at the University of California, San Francisco.

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