State legislation surrounding abortion has left deadly ambiguity for both patients and providers. Several states have placed heavy restrictions on access, allowed only limited exceptions, and given unclear directions surrounding the provision of emergency abortions, putting patients' lives at risk and leaving providers in a state of confusion and fear regarding what type of care they can legally provide.
As these constraints continue, patients seeking such care have been traveling outside their states to clinics where they can receive a medication or procedural abortion, but these circumstances limit access to those with the resources to make the trips.
Nationally, according to multiple surveys, the number of abortions has risen slightly since the Supreme Court overturned Roe v. Wade in June 2022. Yet large inequities exist across individual states. Early this year, procedures dropped most sharply in Georgia, Tennessee, Texas, and other states with six-week bans. In Florida, abortions shrank by a third after similar restrictions took effect this summer.
In response to those bans, people are migrating to organizations and providers in abortion-leniant states. One of these providers is Planned Parenthood Great Plains. Based in Kansas, this branch now serves patients from states such as Arkansas, Oklahoma, and Texas. The organization recently opened a new location in Pittsburg, Kansas, to help deal with the influx.
Think Global Health spoke with Selina Sandoval, MD, a board-certified OB-GYN and Complex Family Planning physician and associate medical director at Planned Parenthood Great Plains, about the realities of abortion care during this time, how providers are handling the overflow of patients seeking reproductive care, and what the future could hold after the U.S. election on November 5.
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Think Global Health: Prior to the Dobbs v. Jackson Women's Health Organization decision to overrule Roe v. Wade and Planned Parenthood v. Casey, how would you describe access to reproductive care and the general attitude toward abortion in the area you serve?
Sandoval: I'm based out of Kansas City and provide all my care on the Kansas side.
What shocks people is that, even before the overturning of Roe v. Wade, abortion was essentially inaccessible in many states.
It is incredibly rare to get an abortion in a hospital in Kansas. This is similar in many of the midwestern and southern states. Even if you're in a state that has legal protections, many of the hospitals have religious affiliations or are state owned and have their own restrictions.
In Kansas, for example, a state mandate dictates that no state employee can participate in abortion care—meaning that the only abortions that occur in a hospital in Kansas are explicitly due to a threat to maternal health. Even some patients with nonviable fetuses can't get approved inside the state.
In Missouri, outpatient care was almost completely inaccessible because of the number of targeted restrictions on abortion providers (TRAP) laws that were in place in the state.
No other portion of health care is regulated this way
Just for clarification, a TRAP law is a state regulation that is medically unnecessary and exclusively politically motivated to limit abortion access. These laws can require abortion providers to meet certain qualifications, such as having inpatient or admitting privileges, regulating who can perform those abortions, or imposing building restrictions or structural requirements on abortion clinics.
The number of laws in place before Dobbs shows the reality of how the overall attitude toward reproductive health care was still incredibly negative and hostile, and that in many states abortion care was already inaccessible to the average person.
Think Global Health: You said people are traveling to your clinics for care, and I want to get a sense of how long it typically takes them. What are the top three or four places they typically come from?
Sandoval: More than 75% of our patients come from Texas and Oklahoma. Our average patient travels somewhere between six and nine hours to come see us. Something people don't consider is that only people with means can travel.
People who are affected by these laws most aggressively are those already living in poverty or low socioeconomic status, so to travel nine hours one way, they need to take a day off work, set up childcare, and lose income for at least two days.
I have patients who have a 10:00 a.m. appointment and they put their kids to sleep and start driving at midnight to get to us.
It's devastating to have to turn someone away. This happens almost exclusively to someone who's too far along in their pregnancy, but we will try to offer alternative services and resources to rearrange their care. It's not always just getting access to an appointment; it's also rearranging their whole life again.
No other portion of health care is regulated this way.
Think Global Health: What are the most common services your center delivers now? Does this portfolio differ from what it was doing before Dobbs?
Sandoval: Most abortions in the United States are medication abortions, and Planned Parenthood Great Plains has made a big effort to increase its procedural services for multiple reasons.
For one, telehealth abortion care has been incredibly helpful, especially for patients, because providers who are in states with shield laws, which protect the ability to send abortion medications through the mail or telehealth, have lessened the burden in that people can access medication through them.
At our new facility in Pittsburgh, Kansas, we have started procedural services, and we are constantly increasing the procedural services we offer at the Kansas City location. We also do procedures out of our Wichita location, which we finally are working on expanding as well.
That's been our main shift, considering that it can be harder to get a procedural appointment and that patients who are beyond about 12 weeks typically are going to have a procedural abortion. Providing access to care for patients beyond that first trimester window is really important to us.
Think Global Health: Based on what you see daily, how would you describe how providers in your clinics are feeling as they deal with the increased flow of patients from states with restricted access to reproductive care?
Sandoval: People who go into this care are so passionate about the work. It's truly a calling to everyone in our clinic.
In the past, a lot of our turnover had to do with some emotional burnout. Patients are incredibly emotional when they arrive and, especially for our providers doing intake, you're hearing these heartbreaking stories repeatedly and it's difficult to take all that in your heart and then go home and have a normal day.
As the world has become more hostile toward abortion access, staffing has become increasingly difficult at the clinic, but all our team members right now are so supportive of each other. It's meaningful work. I think that the people who can do this long term, like me, are taking this emotionally heavy burden and turning it around and realizing that we are making a difference and helping people control their lives, bodies, and autonomy.
Think Global Health: According to your bio, you work directly with fellows, residents, and medical students. How do you think these bans are impacting the education of students who wish to specialize in women's health?
Sandoval: The fall of Roe has absolutely affected training. Here at Great Plains, we do work with medical students and residents. We also have our own clinical-based fellowship program, and we often take fully graduated physicians to offer them training. We're very passionate about training, but we also have the volume to train and the skill set to keep people safe during training.
Prior to Dobbs, of the 286 residency programs, about 49% were offering routine abortion training, but now 19 of those have lost the ability to train.
Now some residents are unable to train in their own states. Some programs are trying to send their residents out of state, but that is limited. Access to this training is plummeting and people need these skill sets.
It's truly a matter of life and death for a lot of people the United States, whether they can access abortion care
At times during my residency, because I had done extra abortion training, I was the only one physically in the hospital who had the specific skills vital to saving a patient's life.
This training is not just about abortion care, it's about full-spectrum reproductive health care, including obstetrical care. It is lifesaving work. Lack of access to this training is going to compound the already increasing maternal morbidity and mortality rates we're facing in the United States.
Think Global Health: From your perspective, what could be done to help alleviate some of the pressure on the physicians in your clinics as they try to provide quality care to patients in need?
Sandoval: Donate to abortion funds, our patients are the ones who need our help. The times that I do feel burnout is when I'm turning patients away.
The majority of our patients receive some sort of funding from an abortion fund in our region to access their abortion. We try to make every effort we can to make it as affordable as possible, but at the end of the day we have to keep our doors open and so there are costs that go into a medication or procedural abortion. Donating directly to abortion funds is the best way to alleviate stress and burden for every single person in the clinics.
Think Global Health: The U.S. election is coming up quickly. What's your plan for the future if Kamala Harris wins? What's your plan for the future if Donald Trump wins? What impact do you foresee the election outcome will have on this situation both for women who seek reproductive care and for physicians that provide this care?
Sandoval: My recommendation to people this upcoming election is to take a very close look at the efforts that your state is making in abortion care. For example, in Missouri, we have Amendment 3, where we're trying to put abortion on the ballot to end the statewide abortion ban.
The possibility of Donald Trump being elected is quite terrifying. There are reports that people that he plans to hire plan to come after abortion providers and they've talked about reinterpreting old laws to come after abortion providers. It is truly terrifying to think about what could happen not only to patients, but also to providers and the health-care teams that take care of these people by doing their jobs.
On the other hand, Kamala Harris has made it evident that she plans on supporting abortion access to the best of her ability. Harris has done a tour of the United States, specifically looking at reproductive health access. She has met with many of my colleagues to talk about what we're seeing on the ground in abortion care. She has made a very clear effort to understand the reality of what's going on throughout the United States, regardless of the physical action she could take during her vice presidency.
It's truly a matter of life and death for a lot of people the United States, whether they can access abortion care.
