0:08

I'll remember it for the rest of my life. It was

0:10

like six of us sitting together, so

0:13

excited for the future. It's

0:16

a Friday in June of 2022, and

0:19

it's Lindsay's first day of her residency,

0:21

which means she is officially a doctor, but

0:24

has four more years of specialty training. Her

0:27

training is underway in a big conference room filled

0:29

with hundreds of other first-year residents.

0:32

She's one of six who are doing their specialty in obstetrics

0:35

and gynecology, or OBGYN.

0:38

We kind of all got the notifications on our phone at once,

0:40

and we looked at each other and we were like, is

0:43

this real? Are you guys seeing this? There

0:45

were tears, and we were so

0:48

panicked about what this meant.

0:52

The United States Supreme Court has just

0:55

issued its decision on the case of Dobbs

0:57

v. Jackson Women's Health Organization, which

1:00

concluded that there is no constitutional right

1:02

to abortion.

1:04

The Dobbs decision overturns Roe

1:06

v. Wade, leaving the power to regulate

1:08

abortion rights up to individual states. Lindsay's

1:11

residency program is in a conservative state

1:13

in the South. I think it's just this

1:16

fear of realizing people who can get

1:18

pregnant have just lost their choices. And

1:21

I was just like, I'm going to fail my patients. I'm

1:23

going to have to turn people away.

1:26

Across

1:26

the country, thousands of OBGYN

1:29

residents are having the same realization. Effective

1:32

immediately, abortion is banned

1:35

in 12 states. Fast

1:37

forward to today, almost exactly

1:39

a year later, and nearly 60% of all

1:42

U.S. women live in

1:44

a state that bans or severely restricts

1:46

abortion. And about half

1:49

of the country's OBGYN residents, like

1:51

Lindsay, have lost the opportunity

1:53

to learn how to perform one.

1:58

There's been so much important reporting. and storytelling

2:01

over the last year about how these bans

2:03

are impacting patients in all kinds of ways.

2:06

Today on the show, we want to focus on a different

2:08

aspect of the story. The impact

2:10

that abortion bans are having on the education

2:13

and skills of healthcare providers, and

2:15

the devastating ripple effect on current and

2:17

future generations of patients, those

2:20

seeking abortions, and those in need of

2:22

other reproductive care like miscarriage management

2:25

and life-saving procedures. Plus,

2:28

we uncover the centuries-long fight over

2:30

who gets access to abortion training in the

2:32

first place. From

2:35

KCRW, you're listening to Bodies. I'm

2:37

Allison Behringer.

2:46

Ask anyone who's been through residency, and they'll

2:48

likely describe some of the most grueling and

2:50

challenging years of their life.

2:52

You have very little control over your schedule, and

2:55

you consistently work 80 hours a week on

2:57

a small salary.

2:58

And every couple weeks, you're on a different rotation,

3:01

focusing on a new area of your specialty.

3:04

And you're simultaneously playing these two roles,

3:06

both as a doctor treating patients at a

3:08

hospital,

3:09

and as a trainee,

3:11

learning new skills under the supervision

3:13

of the attending physicians.

3:15

Lindsay's first two rotations were

3:17

on labor and delivery.

3:19

Her next rotation was family planning, which

3:21

includes abortion training. But

3:23

right before that rotation, Lindsay's

3:25

state started to enforce a law that

3:28

bans abortion at any stage of pregnancy,

3:31

with just a few medical emergency exemptions.

3:34

The abortion clinics closed the very day

3:36

she was supposed to start training.

3:39

My entire goal in being an OBGYN was to

3:41

provide this full spectrum of care to people

3:43

in these huge life

3:45

events. And I feel

3:48

like part of it just got kind of like closed

3:51

off the minute I became a physician. If

3:53

I can't do abortion, I'm not going to have

3:55

this skill set that I think is really important

3:57

to being good at my job. The

4:00

new law in Lindsay's state also made it a

4:02

criminal offense for a doctor to provide an

4:04

abortion and by extension to train

4:06

someone how to provide one.

4:08

Lindsay is not her real name, by the way. Over

4:11

the course of reporting, I've spoken to over a dozen

4:13

residents in restricted states, very

4:15

few of whom felt comfortable being recorded.

4:17

For this reason, we're not using their real names

4:20

nor their states or institutions.

4:23

Throughout the fall of 2022, Lindsay dealt with the

4:26

consequences of the ban nearly every day.

4:29

Like any time a person came in with an ectopic

4:31

pregnancy, which is a potentially

4:33

fatal condition where the fertilized

4:35

egg implants in the fallopian tubes and

4:38

has zero chance of viability,

4:40

Lindsay was taught that she still needed to inform

4:42

the patient about the option of adoption.

4:45

We train in medical school and residency

4:47

to follow the evidence and to do

4:50

what the science shows to protect

4:52

our patients and their health. And so

4:54

it just goes against everything that

4:56

we learn as physicians.

4:59

I think a common scenario is this concept

5:01

of PPROM or preterm

5:03

rupture of membranes. So people whose water

5:06

is breaking well before they're

5:08

due to deliver and well before

5:10

their fetus has

5:12

developed what it needs to

5:14

survive. And it poses great risk to

5:17

the pregnant person because once

5:19

the water has broken, the chances of infection

5:21

and other complications goes up

5:23

significantly.

5:25

We find ourselves

5:27

unable to act until things

5:30

escalate to a point of risk

5:32

that in the past we probably never would have

5:35

seen.

5:38

Under her state's new law, if there

5:40

is cardiac activity in the fetus, even

5:42

if the fetus will not survive, Lindsay

5:45

cannot provide the option of an abortion.

5:47

I

5:48

have seen several cases of

5:50

people whose water broke well before

5:53

their fetus was viable and they were forced

5:55

to wait until they became infected

5:57

or acutely ill to receive care. or

6:00

they had the choice to get in their car and drive

6:02

to another state.

6:09

Residency

6:09

is a bit like an apprenticeship. At

6:11

first you're doing a lot of observing, then

6:14

you begin assisting with hands-on guidance

6:16

from your attending physician.

6:18

And then as you build confidence, you

6:20

progress to treating your patients yourself under

6:22

supervision. But Lindsay

6:24

is learning with her hands tied. She

6:27

says that instead of things getting easier and easier,

6:29

in some ways they're getting harder.

6:32

There's this trauma that I think my co-residents

6:34

and I carry with us and it just

6:37

feels like the antithesis of what residency

6:39

is supposed to be. We're coming into these

6:42

next cases and meeting these next patients with

6:44

anxiety and with uncertainty

6:47

and with fear for

6:48

what's going to happen to them. I

6:50

chose OBGYN because I wanted to be able to take care

6:52

of people from start to

6:54

finish through incredibly difficult situations

6:57

and I wish I could stand by patients but instead

7:00

I'm forced to prolong their

7:02

suffering or turn them away and ask them to go elsewhere.

7:04

And it's just not the physician

7:06

I ever wanted to be.

7:15

There are two main categories of abortions, medication

7:18

and procedural. Medication abortion

7:21

is the most common way that people end a pregnancy

7:23

and it's used in the first trimester. Providers

7:26

of medication abortion need to learn how to counsel

7:29

patients and prescribe the medication. Pretty

7:31

straightforward. As for procedural

7:34

abortion, there are a couple different options. Some

7:36

are more complex for more advanced or complicated

7:39

pregnancies but the most common

7:41

is the MVA, manual vacuum

7:43

aspiration.

7:44

That's using basically a small manual

7:47

vacuum or aspirator to gently

7:50

suction the pregnancy from the uterus.

7:52

Then there are also what's called DNCs. It's

7:55

a dilation and curitage where we use a

7:57

small instrument to kind of scrape

8:00

the incense of the uterus to make sure there's nothing

8:03

retained. Both of these methods

8:06

are also relatively straightforward to learn. They

8:08

are extremely safe for patients, safer

8:11

than a colonoscopy, actually. And there

8:13

are very few complications.

8:15

And it's not as if it takes hundreds of procedures

8:17

to get the hang of the skill. But the thing

8:19

is, trainees learn how to handle complications

8:22

by witnessing complications. And

8:24

so trainees need a super high volume

8:27

of cases to increase their chances of

8:29

dealing with the complications. And

8:31

here's the really important thing to note. Providing

8:34

an abortion to someone is the exact

8:36

same procedure as providing miscarriage

8:38

management, or providing the care that

8:40

could save the pregnant person's life in an emergency

8:43

situation.

8:44

It's the same skill, just different

8:46

context.

8:47

And this is why abortion is such a foundational

8:50

skill for any OB-GYN or

8:52

reproductive healthcare provider.

8:54

For example, the residency director

8:56

at University of Wisconsin told me that

8:58

since the state banned abortion in 2022, she's

9:02

noticed that her first-year residents, who haven't

9:04

gotten any practice with abortion, have

9:06

lower competency in basic skills

9:09

like miscarriage management than

9:11

compared to previous classes. And

9:13

a research paper out of Penn State that surveyed

9:15

fourth-year residents found that those

9:18

with the most abortion training felt the most

9:20

prepared to handle early pregnancy loss.

9:27

After medical school, residency is when

9:29

you decide on your specialty, like if you

9:31

want to be a family medicine doctor or an

9:33

OB-GYN.

9:35

And where you end up for your residency almost wholly

9:37

determines the kind of training that you'll get and

9:40

your opportunities down the line. And so,

9:42

residency hopefuls spend a lot of time making

9:44

their ranked list of favorite programs, hoping

9:47

that they'll be selected in turn by a program

9:49

that offers the best training for their desired specialty.

9:53

Lindsay grew up in the north, but after doing

9:55

medical school in the south, she felt drawn

9:57

to a southern residency that she knew offered a better

9:59

place.

9:59

I felt like a lot of

10:02

my friends back home and

10:04

my family back home, we had these progressive ideals, but

10:06

no one was even in a

10:08

place to practice those ideals and kind

10:11

of be walking the walk on a day-to-day basis.

10:14

And I felt like my time

10:16

in the South, I fell in love with grassroots

10:18

organizations and how change happened.

10:21

And like, I feel like progressive

10:23

people in the South are fighting

10:25

a way harder battle and often show

10:27

a lot more dedication to that battle.

10:29

But when Lindsay

10:32

ranked her residency program, she didn't realize

10:34

that the battle was going to include fighting for the

10:36

right to abortion training. I think

10:38

it's important to note that many of us in

10:40

these training programs never thought

10:43

we'd be in a place where abortion's illegal.

10:46

Instead of training with patients, her

10:48

program had to adapt. Lindsay

10:50

and her fellow residents trained on plastic models

10:52

of reproductive organs and on papayas.

10:56

It turns out the fruit is a pretty good replica of

10:58

the uterus.

11:02

And the thing is, even before DOBs,

11:04

not all residencies provided the same

11:06

level of abortion training. In

11:08

fact, a 2018 study

11:10

out of UC San Francisco found

11:13

that only about two-thirds of OB-GYN

11:15

residency programs routinely trained their residents in abortion

11:17

camps.

11:19

So the Accreditation Council for Graduate

11:22

Medical Education, or ACGME,

11:25

is the body that sets training standards for

11:27

all branches of medicine.

11:29

And after Roe v. Wade granted the right

11:31

to abortion in 1973, the ACGME

11:34

was supposed to develop training standards

11:36

for abortion. But it

11:38

didn't. And by the early 1990s, only 12%

11:40

of OB-GYN programs offered training in abortion

11:43

care. In

11:46

response, a group called Medical Students for

11:48

Choice started advocating for this training.

11:51

And in 1995, nearly 20 years

11:54

after the passage of Roe, the ACGME

11:57

finally set standards for abortion training.

11:59

But then politicians got involved. What

12:03

happened is Congress immediately

12:05

passed a law basically

12:07

saying, you residency

12:09

programs, you don't have to conform

12:12

with this. We will still send you money

12:14

even if you don't live up to this standard.

12:17

This is Carol Joffe, a sociologist

12:20

who's been studying abortion provisions for over 40

12:22

years. Her most recent work

12:24

is about the gaps in abortion training post-dobs.

12:27

That is just a very direct example

12:31

of the incredible stigma of

12:33

facing abortion

12:33

or what I like to refer

12:36

to as, quote, abortion exceptionalism,

12:39

the idea that abortion is treated differently

12:43

than any other branch of medicine. A

12:46

lot of my scholarship has been about

12:48

this very point. What

12:50

didn't happen after Rowan? Why? And

12:53

here's my answer. In

12:56

medicine itself, there was a

12:58

lot of discomfort

13:00

and ambivalence

13:01

around abortion. See

13:04

before abortion was legalized, there were doctors

13:07

who took the risk to provide abortions. There

13:09

were also non-medical, everyday people

13:12

providing abortions. So many

13:14

women were coming into emergency

13:16

rooms, you know, bleeding. Either

13:18

they had tried to do their own abortions

13:21

or they had gone to a so-called butcher.

13:24

And it was these so-called butchers who

13:26

captured the popular imagination of the

13:28

public and of the medical community.

13:31

Mainstream medicine, even though they wanted

13:34

abortion to be legal, they didn't

13:36

feel good

13:37

about the abortion provider. They

13:40

thought all of them were butchers, which

13:42

was not true, but that's what

13:44

they thought.

13:45

So they didn't set up training. They

13:47

didn't set up clinics in

13:49

their hospitals. And as abortion became

13:51

more and more politicized, the government

13:53

passed an amendment that barred federal public

13:55

funding for abortion. At the same

13:58

time, some state legislators

13:59

and conservative states refused

14:02

to give money to public hospitals and universities

14:04

if they offered abortion training. So

14:07

the training had to be moved to independent freestanding

14:09

clinics like Planned Parenthood. To help

14:12

connect residents with actual solid abortion

14:14

training, various abortion

14:17

rights organizations took it upon themselves

14:19

to work with some residency programs to

14:21

navigate all these barriers and actually

14:23

meet the official standards.

14:25

And that's how the country's abortion training became

14:28

a mishmash of standards and availability.

14:31

These politicians don't, some

14:33

of them do not give a damn whether

14:35

women live or die. There's

14:39

a huge shortage of OBGYNs in the

14:41

United States. The American College

14:43

of Obstetricians and Gynecologists recently

14:45

predicted that by 2050 there'd

14:48

be a shortage of over 22,000 of these doctors.

14:51

This shortage is especially felt in rural communities

14:54

and has created so-called OBGYN

14:56

deserts. In the rural communities,

14:59

the majority of the obstetrical

15:01

care is

15:02

being provided by family-owned physicians. This

15:05

is Natalie. She's in her third and final

15:07

year of residency for the Family Medicine

15:09

specialty.

15:10

Again, we aren't using her real name or

15:12

any specifics about her location. Natalie

15:15

got inspired to become a rural family

15:17

medicine doctor when she was working in public health, making

15:20

sure rural hospitals were meeting the needs of patients.

15:23

In working with these communities and working

15:26

with the physicians there who

15:28

were almost exclusively family medicine

15:31

physicians, something

15:33

kind of clicked and I just

15:36

kind of felt like I'd found my people. And

15:39

certainly as a BIPOC person,

15:41

I feel very strongly how

15:45

important it is to have a physician

15:47

who looks like you. Data

15:49

show that people get better care

15:52

from people who look like them too. And

15:54

so I feel really passionate about that piece of it.

15:58

Natalie also knew

15:58

she wanted to incorporate the research into the public health department.

15:59

to incorporate abortion training into her practice. She'd

16:02

witnessed the lack of access to abortion and

16:05

reproductive health care in rural areas.

16:07

The thing is, getting abortion training is

16:10

even harder for family medicine doctors than

16:12

it is for OBGYNs. Roughly

16:15

only 5% of family medicine residencies offer

16:17

abortion training. So when Natalie

16:19

was coming up with her rank list for family medicine,

16:22

ranking one of those few programs was a big priority.

16:25

She matched at her first choice at a hospital

16:28

in a small city that serves the surrounding rural

16:30

population.

16:32

It felt like a world of possibilities

16:35

were open to me as a first year resident.

16:38

There's no other field that lets

16:40

you deliver a baby and talk

16:43

to a nice 80 year old lady about, you

16:46

know, her urinary symptoms and

16:48

switch and talk

16:50

to a kid about their asthma. And I

16:52

loved being able to take care of the entire

16:54

family. There's just something really

16:56

special about that.

17:00

During her first two years, Natalie learned

17:02

how to provide medication and procedural abortion

17:05

at the local Planned Parenthood.

17:07

The method of doing a first trimester procedural

17:09

abortion is relatively uniform, but

17:12

every provider has their own unique style.

17:15

Like Natalie, she's short and has

17:17

small hands, so she learned a lot by

17:19

observing providers with a similar stature,

17:21

how they grip the instruments and how they position

17:24

their bodies. Going

17:26

into her third and final year, she was on the brink

17:28

of competency.

17:30

But after Roe fell and legislators in her

17:32

state voted to ban abortion, the

17:34

opportunity to further hone her skills

17:36

vanished. I have worked really hard

17:39

to make sure I am a safe

17:42

and responsible provider and

17:46

to be told by someone with no medical background

17:48

whatsoever of what I can and cannot do

17:50

is hard to

17:53

take. For

17:54

the first time, she found herself living

17:56

with the fear that if she tried to help someone

17:58

with their miscarriage,

17:59

She could get maybe sued

18:02

or maybe put in jail. The

18:04

laws were confusing and unclear.

18:07

She also started having to turn away patients

18:09

who wanted to end their pregnancies. There

18:11

are so many emotions and

18:13

just feeling that

18:16

sense of powerlessness

18:20

and that sense of inadequacy

18:24

of this person is trusting me

18:27

with her care

18:29

and I can't provide what

18:32

I should be able to. And

18:34

it just makes me really sad for our

18:38

patients. Natalie

18:40

has also seen firsthand how severe

18:43

the consequences of the lack of abortion

18:45

training can be.

18:46

There was one patient who lived hours away

18:49

from Natalie's hospital in a rural community.

18:52

She had just given birth but she had a complication

18:54

and started to hemorrhage.

18:56

She had to be life flighted to Natalie's hospital.

19:00

And she

19:03

died because she essentially

19:05

bled out in the plane. And

19:08

that's a delay, right? That was a delay in care.

19:11

They couldn't stabilize her in her

19:15

home, in her community. And

19:18

so she died. I

19:20

don't think there were any OB

19:22

guides in that community. And

19:24

so I don't think there were any providers who could

19:28

do the surgery that she would have needed.

19:31

And I think it only highlights

19:35

the damage that these restrictive laws have,

19:38

especially on specific populations.

19:42

Like our rural patients, our poorer

19:44

patients, and then our patients of color.

19:55

The thing about these abortion laws is that

19:57

the states that are the most restrictive with

19:59

abortion

19:59

already, and historically,

20:02

have had some of the worst reproductive health

20:04

outcomes. Louisiana, for example,

20:07

has the worst maternal mortality rate in the country.

20:10

It also has some of the most restrictive abortion

20:12

laws.

20:13

In fact, nine of the ten worst states

20:16

for maternal mortality are in abortion-restricted

20:19

states.

20:19

And according to a report by the Gender Equality

20:22

Policy Institute published in January

20:24

of this year, women living in a state

20:27

that banned abortion after dobs were

20:29

three times more likely to die in pregnancy,

20:31

childbirth, or soon after giving birth. Babies

20:35

born in banned states were 30%

20:37

more likely to die in their first month of life.

20:40

That same report found that 70% of

20:42

black women, as compared to 60%

20:44

of all women, live in restricted states,

20:47

and that black women were three times as likely

20:49

to die in pregnancy, childbirth, or

20:52

right after giving birth, as compared to white

20:54

women. Many of the

20:56

people that we spoke to predicted that

20:58

all of the new abortion bans are going to make these

21:00

disparities worse.

21:04

When the dobs decision passed, residency

21:06

directors in conservative states were scrambling.

21:09

They were making phone calls to friends and colleagues across

21:11

the country in abortion-protected states,

21:14

asking them, please, would you take on my residence?

21:17

Like, even if they could no longer legally

21:19

provide training to their residents, maybe

21:21

their residents could do a short away rotation

21:24

in another state to get those skills. Of

21:26

course, program directors in abortion-protected

21:28

states have to weigh whether their program

21:31

actually has the capacity to take on out-of-state residents,

21:33

on top of

21:34

their own residents. And then

21:36

there's funding to consider.

21:37

Like if a program is state-funded, it's unlikely

21:40

that it'll cover the salary of a resident while they're

21:42

in another state. There's also travel

21:44

expenses and lodging.

21:46

And they need to sort out my practice insurance

21:48

and a medical license in another state. But

21:51

against all odds, Lindsay's program organized

21:54

a series of month-long away rotations

21:56

in the Northeast for its first-year residents.

21:59

Lindsay is concerned.

21:59

that naming the host institution or even

22:02

the host state could jeopardize this opportunity

22:04

for others.

22:06

As far as we know, our state

22:08

legislators are not aware that we're traveling

22:11

to this other state for training.

22:13

I don't want our governor

22:15

and our legislators to know any of the details of what we're

22:18

doing and why because I would be really

22:20

sad to see this training

22:22

restricted.

22:25

After the break, Lindsay performs

22:27

her first abortion.

22:34

Are we ever going to get to universal health care in America? How did Jules jumpstart

22:36

a new epidemic

22:39

of teen smoking? I'm Dr. Abdul Elsayed and each week

22:41

on America Dissected, I speak with the doctors, scientists and

22:43

culture makers shaping the future of health

22:45

and society. Together, we dissect

22:48

how scientific discoveries, trillion dollar

22:50

policies and cultural trends are changing the

22:52

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23:07

And we're back.

23:08

Lindsay was the first in her cohort to go on an away

23:10

rotation to the northeast. And

23:12

so in January of 2023, Lindsay got on a plane. And when

23:15

she landed, it was a new world.

23:16

She

23:19

was excited, but nervous. Whenever

23:22

you do a procedure for the first time as a resident, there's

23:24

this imposter syndrome and there's this huge

23:27

anxiety of like, I have to do this well. Like

23:29

what if I mess up

23:32

for Lindsay's first abortion for a patient with

23:34

a seven week pregnancy, her supervisor

23:36

or attending physician was with her

23:39

the whole time.

23:40

Lindsay started by giving her patient options.

23:43

I offered medication to the Mipha

23:45

Pristine and Mesoprostol. And then I offered

23:48

the vacuum procedure and I told her that we could

23:50

either do it in the office with local anesthesia or

23:52

in the operating room under general anesthesia.

23:55

The patient decided that she wanted to stay in the office

23:58

and get the vacuum procedure, which is a very important thing.

23:59

again is the most basic and common

24:02

procedural abortion.

24:03

I explained to her that it would be me

24:05

and my attending physician and

24:07

I actually told her I had not

24:09

yet done this procedure but that my attending

24:12

would be very hands-on helping me

24:14

and she was like really happy

24:17

to help me with my education which

24:19

patients are usually really gracious about that.

24:22

The first part is very similar to a pelvic exam

24:25

so obviously I'm confident in that at this

24:27

point so I placed the speculum, I placed

24:29

the clamp on the cervix, I

24:32

inject with

24:32

local anesthesia. Lindsay

24:35

placed the vacuum so that it was at the top of the uterus.

24:38

Her attending physician checked the placement. When

24:41

you use a vacuum and a manual

24:43

vacuum aspiration you twist

24:46

it and kind of spin it so that it

24:48

covers all the surfaces of the uterus and

24:51

I think it's just one of those things where someone

24:53

explains that to you and you watch them do it but then in real

24:56

life you're like do I spin this quickly?

24:58

My attending kind of had her hand on top of mine

25:00

turning my hand how she would do it herself

25:03

and so it helped me develop my own habits

25:05

and muscle memory.

25:07

The procedure went well. Lindsay and

25:09

the attending cleaned up the instruments and

25:11

then made sure the patient was feeling okay. I

25:14

expected myself to feel like

25:16

this wave of feelings afterwards but I wouldn't

25:18

say that there was like

25:21

a moment where I was like oh my gosh I just did

25:23

something so profound.

25:25

It just felt like going to work and providing

25:27

medical care which we do every day. It

25:30

was a constant reminder that abortion is

25:32

common and it's normal and it's safe

25:36

and I left that day feeling so like

25:38

light and happy compared

25:41

to what I normally feel in

25:43

my home state where sometimes I carry home

25:45

this burden of like I spend

25:47

a lot of time at home thinking about like I

25:49

wonder if they're going to try to self-manage

25:52

their abortion at home like I wonder what they're gonna do

25:55

whereas in this other state I

25:57

knew the ends to those stories because they chose

25:59

them in

25:59

front of me with every piece of information

26:02

available. But

26:06

this away rotation wasn't without sacrifice.

26:09

In order to make sure that the hospital back home had

26:11

coverage, Lindsay's fellow first years

26:13

were picking up extra shifts to cover for her.

26:16

She'd do the same when she got back when others

26:18

left for their rotations.

26:21

In fact, the night she got home, she went

26:23

directly from the airport to the hospital for

26:25

a shift. Meanwhile,

26:28

Natalie, the family doctor in training, wasn't any closer to completing her abortion

26:30

training. Her

26:32

residency director hadn't been

26:34

able to organize an away rotation for all the residents. So

26:37

Natalie arranged one herself. She

26:40

applied to a program called Midwest

26:41

Access Project that connects

26:44

residents in need of more thorough abortion

26:46

training with away rotations. Natalie's

26:50

application

26:51

was accepted, and a few grants came through

26:53

as well. She would be spending two weeks at an

26:56

abortion clinic in Minnesota, a state that protects the

26:58

right to abortion. I spoke to Natalie

27:01

in Minnesota when she was halfway through

27:03

her away rotation. There's

27:05

that ever-present

27:06

fear that I

27:08

don't think I really realized was there until I was in a place

27:10

like this where I didn't have to worry about

27:12

it, and then realizing, oh, there was that weird

27:15

tension that I was feeling. I

27:19

can tell you I am absorbing

27:21

so much more here than I have before. There's

27:26

just a different sense of not feeling

27:28

afraid anymore,

27:30

which will come back as soon as I go back. In

27:33

Minnesota, Natalie was getting to do multiple

27:36

procedural abortions every day. She

27:38

was finally the doctor

27:39

that she wanted to be for her patients. Almost

27:43

every single one, you have that moment where

27:46

they look up at you, and you

27:49

kind of just

27:52

lock eyes for that

27:54

moment, and they just say, thank you so

27:56

much for helping me with this. You

27:58

can see the relief in the end.

27:59

their face and you can see and hear

28:04

just how grateful they are that

28:06

you were there and that you helped them through

28:09

this.

28:10

Being in this clinic and

28:12

seeing the impact you have on

28:15

these patients and being able to offer

28:17

this service

28:19

only furthers my resolve

28:22

to help with this and to fight for

28:24

it.

28:27

Really in Lindsay, in a way,

28:29

they're the lucky ones. With all the barriers

28:32

and the limited space available, the vast

28:34

majority of residents in restricted states

28:36

have not been able to leave their state to get trained.

28:39

Like Lindsay told me that she personally doesn't know

28:41

of anyone else in the South who is getting the opportunity

28:43

she did. I spoke with a number of

28:45

residents who went into their programs expecting

28:48

top-notch abortion training and

28:50

are finishing their year without any.

28:53

I also talked to OBGYN graduates who

28:55

are in the midst of pursuing additional years of even

28:57

more specialized training. These are the doctors

29:00

who need to learn how to handle the most complex abortion

29:02

and pregnancy loss situations. They

29:05

all told me about the heartbreak of watching patients

29:07

suffer

29:08

and the frustration of not being able to get the training

29:11

that they wanted.

29:19

Doctors aren't the only ones who've had their abortion

29:21

training taken away. For decades,

29:24

nurse practitioners, nurse midwives, and

29:26

physician assistants have also been

29:28

pushing for this training and for the right

29:30

to put that training to use. There's

29:32

a deep bench of thousands of these healthcare

29:34

providers who have the potential to make

29:37

abortion more accessible and

29:39

help with the influx of out-of-state patients

29:42

traveling to abortion-protected states. And

29:45

yet, as of 2019, only five

29:47

states allowed nurse practitioners and nurse

29:49

midwives to provide that most basic

29:52

aspiration abortion procedure.

29:54

I spoke with many of these healthcare providers and

29:56

I kept hearing about how providing first-trimester

29:59

medication

29:59

and procedural abortion is not

30:02

any more complex than other procedures that they

30:04

regularly do, like placing IUDs

30:07

or providing miscarriage management or

30:09

delivering babies. And numerous studies

30:12

have demonstrated that they can be trained to safely

30:14

provide medication and aspiration abortion.

30:17

Midwives actually used to be the main providers

30:20

of abortion.

30:21

Long before the United States was even a country,

30:23

long before abortion was criminalized, midwives

30:26

delivered babies, provided abortions, and

30:29

did pretty much everything related to reproductive

30:31

health care.

30:32

The people who were performing abortions

30:35

and providing reproductive health care

30:38

were nearly exclusively women.

30:39

This is Michelle Bratcher

30:41

Goodwin. She's a scholar and professor

30:44

whose work spans health policy and law.

30:47

That knowledge was being passed on women

30:50

to women, and it's important to understand

30:52

that half

30:53

of those midwives were black

30:56

women who had been enslaved,

30:58

who were free. These black women

31:01

accounted for such a large portion of midwives

31:03

in part because they had brought from Africa the plants

31:05

and herbs that induce abortion and

31:08

the knowledge of how to use them. Also,

31:11

during this time, black people in the United States

31:13

held a huge amount of expertise in all

31:15

kinds of fields, and medicine was

31:17

a big one. But around the

31:19

time of the Civil War, both the government

31:21

and a quickly privatizing medical sector

31:24

dismantled that authority.

31:26

White men who wanted to enter the newly founded

31:28

field of OBGYN found themselves

31:30

in competition with these skilled black midwives.

31:33

So these men launched a smear campaign.

31:36

So they begin writing about how the midwives

31:38

are unsanitary, how they're

31:41

engaged in evil practice. And

31:43

the key thing that they use in order

31:45

to push their agenda is to

31:47

say that these midwives are doing

31:49

something that is unholy and evil.

31:52

They're practicing

31:53

abortion.

31:55

In the late 1800s, these white

31:57

male doctors are successful in their campaign

31:59

to ban men

31:59

and Wifery's reproductive care. And

32:02

for the first time in US history, criminalize

32:05

abortion.

32:06

We go from seeing about 100% of reproductive

32:08

health care being

32:10

governed by women to at the

32:13

beginning of the 20th century, it's about 1%. They

32:16

are incredibly successful with pushing

32:18

women out and with making

32:20

sure that medical schools

32:23

bar women from entry.

32:25

Then that also means that

32:28

black women were completely erased.

32:30

The people who had been most relied upon

32:32

in medicine, go

32:34

get the midwife, make sure she's

32:36

here because someone is dying,

32:39

because someone is about to give birth, and

32:41

we need her right away. Go find

32:44

her, go to the next plantation. All

32:46

of that is wiped away. What's

32:48

wiped away

32:49

is the millennia of

32:51

knowledge and practice and cultivation

32:55

and training of others to

32:57

do the work of medicine. And

32:59

it's been for more than a century that

33:02

midwives have been trying to regain

33:05

the presence that they had,

33:07

the respect that they had centuries

33:10

ago.

33:13

In the last two decades, nurse midwives,

33:16

along with nurse practitioners and physician assistants,

33:18

have been making huge strides to regain that

33:21

knowledge and the ability to train the

33:23

next generation. As more states

33:25

begin to allow these providers to practice, more

33:28

training opportunities are needed to catch up

33:30

with the demand.

33:31

Slowly but surely, progress is being

33:34

made. Like recently, when

33:36

a new law in Maryland allowed these providers

33:38

to do abortion, it also included funding

33:40

for training.

33:43

Whenever I ask reproductive healthcare providers

33:45

about themselves, they're always quick

33:48

to center the conversations around the patients.

33:50

Patient health, patient choice, patient

33:53

suffering.

33:54

But healthcare providers are suffering too.

33:57

There's this concept of moral injury.

34:00

when a person feels like they've violated their

34:02

morals or ethical compass because

34:04

of the situation that they were in. For

34:06

healthcare providers deeply committed to reproductive

34:09

healthcare, these moral injuries

34:11

are becoming so great, so extreme,

34:13

that some are leaving their states. A

34:16

few months ago in Idaho, a maternal

34:19

health unit had to shut down because so many

34:21

of its OBGYNs had left the state. According

34:24

to a study by the Association of American

34:27

Medical Colleges, OBGYN

34:29

residency programs in restricted states

34:32

have seen a 10% drop-off in applicants.

34:35

State healthcare systems depend on residents staying

34:38

after graduating and working in local hospitals

34:40

and clinics. These already

34:43

understaffed abortion-restricted states are

34:45

at risk of losing these recent grads. The

34:49

more restrictive the laws

34:51

get, the harder it is for these populations

34:53

to just get general care and

34:56

then you just lose all of that knowledge.

35:00

Natalie is still trying to figure out if she wants

35:02

to stay in her residency state after she

35:04

finishes her program.

35:07

I think at the beginning of residency

35:10

there was a very real chance that I was

35:12

going to stay. I really

35:14

like where I am. I like the people I work

35:17

with. I love my patients. And

35:22

I'm in a state where there's such a need for

35:25

family medicine physicians.

35:27

I have daily conversations

35:29

about, is this worth it?

35:31

Why do you want to help this

35:34

state that's so clearly hostile to you?

35:38

Natalie is testified at state legislature

35:40

hearings about the need for abortion, and she

35:43

can't shake the fear that she might become a target

35:45

for violence for her advocacy, especially

35:48

because she stands out as a person of color.

35:51

I went into this profession

35:53

to help people, and having that fear.

36:00

of all of a sudden being criminalized for

36:02

certain things that I do. It

36:05

makes folks like us not

36:08

want to fight anymore. We're

36:10

just tired of it.

36:12

And I think before there was that,

36:15

well, someone has to fight for it.

36:18

And

36:19

increasingly, I'm starting to wonder

36:22

if that's worth the mental and the emotional toll.

36:26

As

36:30

for Lindsay, when she got back from her way rotation,

36:33

it was straight back to the new normal of post-ro

36:35

America. It's kind of this whiplash

36:38

of being able to do everything for people and

36:40

then being

36:40

back here and kind

36:42

of feeling stuck. Like,

36:45

certainly people are suffering as we speak, but

36:48

it's also a problem in a decade from

36:50

now and beyond when these

36:53

hundreds of residents training in the South didn't

36:55

get the training that they should have. And

36:57

at the same time, Lindsay points out

37:00

that the experience that she's having at her home

37:02

program is actually becoming a necessity.

37:05

Because the reality is, she's getting the

37:07

training on how to handle situations and

37:10

advocate for patients in a post-ro South.

37:12

Like the time when an eight-week pregnant patient needed

37:15

to terminate for health reasons, but didn't qualify

37:17

for the band's exemptions. Lindsay

37:19

and her team spent hours navigating the legal

37:22

minefield and coordinating with an abortion

37:24

clinic in another state so that the patient

37:26

could drive there and get care.

37:28

There are really difficult situations that arise

37:31

when people don't have access to abortion. And

37:33

we're unfortunately becoming experts at

37:35

navigating those situations and supporting patients

37:37

through them. So it's something that I don't

37:40

wish upon anyone else, but I do feel like we

37:42

have become kind of more

37:44

comprehensive in our care because we

37:47

see these really

37:48

unique and awful

37:51

tragedies at our own institution and have

37:53

had to learn to navigate those as well. The

37:56

reasons I did Madison are

37:59

holding true. more here and now than

38:01

I ever would have imagined. And

38:04

it's been a massive

38:06

privilege despite it not always being a happy

38:10

experience.

38:11

There's a huge need for pro-choice

38:15

physicians in the South. I think

38:18

some of us need to stay.

38:20

And I feel strongly about being one

38:22

of those people.

38:23

Just this past month,

38:25

North Carolina banned abortion

38:27

after 12 weeks, and South Carolina

38:29

banned it after six weeks. That's millions

38:32

of people who lost access to abortion,

38:35

and 13 more OBGYN residency programs

38:38

that won't be able to adequately train their

38:40

residents. Thank

38:53

you to Lindsay and Natalie

38:55

and everyone we spoke to for this episode.

38:58

When I asked residents about how they

39:00

dealt with all this fear and frustration and uncertainty,

39:04

they told me about the support from their

39:06

co-residents and attendings and residency

39:07

directors. A team of residents who have been involved

39:10

in the work of the community, and

39:12

the community, and the community, and

39:15

the community, and the community. I

39:18

just wanted to take a moment to acknowledge all the

39:20

communities of people that have been part of this

39:22

season. You, our listeners, included.

39:25

At the beginning of production

39:27

for this season, I read a line by Thich Nhat Tan, and

39:30

it stuck with me all year. It

39:33

goes, We are here to awaken from

39:36

the illusion of our separateness. And I'm

39:38

sure that's what we're all about. I'm

39:41

sure that's what we're all about. And it

39:43

goes, We are here to awaken

39:45

from the illusion of our separateness. I

39:48

think for me, learning from the people

39:50

that we meet in our reporting is that

39:52

awakening.

39:54

I'm also so grateful for the talented

39:56

and dedicated bodies team for making

39:58

this work possible. You're all the best.

40:01

You can find a transcript of this episode as

40:03

well as additional resources on our website,

40:06

kcrw.com slash bodies.

40:09

You can follow bodies on Twitter and Instagram

40:12

at bodies podcast. And

40:14

if you like bodies, consider writing us a review

40:16

on Apple podcasts. This

40:20

episode was reported and produced by

40:22

me, Alison Berenger and Lila Hassan.

40:25

Our story editor is Mira Berwintonic. Additional

40:28

story editing and advising by Cassius

40:30

Adair and Sharon Moshehe. Music

40:33

by Hannis Brown and Dara Hirsch. Sound

40:36

design by Mira Berwintonic. Mixing

40:38

by Nick Lamponi. Transcription

40:41

help from Nisha Venkat. Special

40:43

thanks to Kathy Bacher, Camila Kerwin,

40:45

Kalalia, Caitlin Pierce and Kristen

40:48

Lepore. Episode art by Nika

40:50

King. Cover art by Sarah

40:52

Bachman. Bodies is supported

40:54

and distributed by KCRW. Our

40:56

executive producer at KCRW is Gina

40:58

Delvac. Thank you to the whole KCRW

41:01

team, including Mia Fernandez,

41:04

Kieran Smith, Natalie Hill, Connie

41:07

Alvarez, Scott D'Alavo, Evan

41:09

Solano, Adria Clokey, Ariel

41:12

Torres, Christopher Ho, Laura

41:14

Kondrajian and Alexandra Castle.

41:17

With special thanks to Natalie Kiriakoudis

41:20

and Jennifer Farrow. I'm

41:22

Alison Berenger, host and executive producer

41:24

of Bodies. Thanks for listening.