For more on a post-Roe world, check out our special edition.

In late May, the Boston Globe broke the story of Kate Dineen, who was 33 weeks pregnant with a fetus that had a severe stroke in utero. Doctors at Massachusetts General Hospital refused to provide her a legal abortion under Massachusetts law, which does not allow most abortions 24 weeks post-implantation.

Instead, Massachusetts General convened a so-called ethics committee that included legal representation for the hospital and then chose to refer Dineen to an out-of-state clinic, even going so far as to set up the appointment for her. Dineen paid $10,000 out of pocket and drove 500 miles for the procedure, the Boston Globe reported.

Massachusetts General Hospital is part of Mass General Brigham, a nonprofit network of hospitals that comprise some of the wealthiest and most venerable names in health care, including Brigham and Women’s Hospital. In the first quarter of 2022, the network grossed $4.1 billion in operating revenue.

Most individual abortion funds operate on a massively smaller budget. The gross income of the National Network of Abortion Funds in the entire fiscal year 2020 was just over $11 million.

Today, clinics provide the overwhelming majority of abortion care in the United States; according to Keep Our Clinics, 3 out of 5 abortion patients get an abortion at an independent clinic. While clinics have many advantages, such as being able to keep costs down and streamline safe, outpatient procedures like abortion, their position outside major hospital networks has left them vulnerable to the overwhelming stigma, violence, and legal costs associated with providing abortion care in the country.

So what, if anything, can hospitals do now that Roe is dead? And how can physicians—arguably the most powerful health-care workers in the hospital system—be a part of that change?

Personal responsibility

Dr. Deborah Bartz, an OB-GYN and board-certified specialist in complex family planning at Brigham and Women’s Hospital, divides her time between patient care and research. In her capacity as an academic clinician, she provides abortion care and also trains the next generation of physicians in abortion care.

We chatted the week before the Supreme Court overturned Roe v. Wade about how flagship research hospitals like Brigham and Women’s might expand abortion care to signal their support for that care to the public, and how physicians have a role in pressuring their hospital systems for systemic policy change.

“It really hamstrings us to just talk about academic clinicians when honestly, all physicians have a stake in this. and all physicians can and should put more skin in the game, which includes private, nonacademic OB-GYNs,” Bartz said. “It also includes internal medicine doctors, emergency medicine doctors. I honestly think that I put the responsibility more on individual physicians than I do on hospital systems.”

Bartz said all physicians—regardless of the type of hospital they work in or their specialty—need to make a concerted effort along three fronts: “Become more informed and talk openly about abortion, become more knowledgeable about pathways into abortion care, and consider providing abortion care themselves.”

All physicians can “improve the referral lines, the quality of referrals to get patients into abortion care,” Bartz said. So, for example, “if a patient is in any practice—an internal medicine practice, an emergency medicine visit, what have you—and has an unintended pregnancy and is seeking abortion services, all physicians can and should become better informed about accessing abortion services specific to where they practice,” Bartz said.

In other words, physicians should not be discharging patients seeking an abortion to Google. Rather, physicians should be equipped with an up-to-date knowledge of clinics in their area, relevant legal restrictions, etc.

Bartz practices in a state where Medicaid, as well as most private insurers, cover abortion care. However, when I asked her about the relatively higher cost of hospital abortions, especially when dealing with an un- or underinsured population, Bartz stressed the importance of people donating to abortion funds.

Organizing for change

Shifting the needle for systemic change in hospital policy requires physicians—a highly paid, powerful labor group that nonetheless has never been unionized—to have a plan for how to engage with administrators.

Dr. Alhambra Frarey, an OB-GYN at Penn Medicine, told Rewire News Group that “meeting with health system administrators and using statements of support from professional [medical] organizations is a good place to start.”

Similarly, Bartz said sharing patient stories with administrators is one step to create change from the bottom up. Frarey also suggests “organizing a diverse group of physicians from different areas of practice” to drive home to administrators that abortion care is not an issue narrowly affecting only family practice and OB-GYN departments.

But what policies should physicians attempt to change? Frarey’s recommendations for physicians looking to leverage their unique privilege within hospital systems focused on putting pressure on restrictive abortion care policies, hiring more abortion providers, and providing financial assistance to patients.

For example, some hospitals allow abortions to be performed only for maternal or fetal health indications, even when state law would allow abortions for any reason. Frarey suggested expanding services to reflect the limits of the law in such cases.

But even when hospitals provide care to the limits of the law, they may not have a sufficient number of abortion providers to meet demand, and those providers in turn may not have dedicated time in the operating room. Frarey noted that hiring more abortion providers in hospital settings, ensuring they have dedicated operating room time, and then expanding operating room availability “in anticipation of an influx of patients from restricted states,” would all work together to meet patients’ needs now that Roe has fallen.

As far as funding abortion care, Frarey suggested that hospitals in states that follow restrictions created through the Hyde Amendment, “establish an affordable cash package rate for services.” Hospitals, of course, are not going to want to provide services at a loss. Frarey said physicians could work with abortion funds and hospital administration to establish funding streams for affordable abortion services. Hospitals could then take at least some of the caseload off already overworked clinics.

Worst-case scenarios

A practicing emergency physician in the Bay Area working at a nonacademic hospital articulated a sense of powerlessness among many physicians to leverage their labor power collectively, due to the way that their training teaches them to show up “even when working conditions are dangerous or unhealthy” for themselves or for patients.

“Maybe I should be willing to lose my job. I can get another job,” the physician, whose name is being withheld for privacy reasons, said.

The “culture of medicine,” they pointed out, teaches physicians that they do not hold the power to collectively influence a system within which they nonetheless wield immense individual power. But that power will be needed now more than ever.

Practically, the physician stressed the need for emergency departments to prepare for the “worst-case scenarios” that family care physicians and OB-GYNs consider extremely unusual, such as complications from procedural or medication abortions.

“That’s really my job, to anticipate the worst-case scenario, and then I can manage anything else,” they said before Roe was overturned. “It may not be common after Roe falls that we see complications from self-managed abortions coming into the emergency department,” they insisted, but uncommon “is not zero.”

The physician said that currently, emergency physicians are primarily tasked with managing ectopic pregnancy, which is when a fertilized egg implants outside the uterus. One avenue to expand care is for emergency physicians to broaden their training to include more education in miscarriage management and manual uterine aspiration (MUA). Physicians, the anonymous physician suggested, could work with administrators to provide abortion care within the emergency department whenever legally possible.

Asked about the role of large research hospitals and whether they bear a particular responsibility in the current ecosystem of reproductive health care, they said, “I do think it would be incredibly helpful for big academic centers to publicize their support of abortion care.”

“These centers are the ones publishing studies and establishing new guidelines of care nationally for all fields of medicine,” the physician added. “So, just in the way we look to them to say what’s the most up-to-date treatment for an aortic valve replacement, having them state that they publicly support abortion care as good, high-quality care for patients—that would be very powerful and empower all hospitals to follow suit.”

Stronger together

The medical-legal environment now that Roe has been overturned is still murky, particularly around issues like the Emergency Medical Treatment and Labor Act (EMTALA) and the extent to which the Biden administration might choose to penalize hospitals that do not provide lifesaving abortion care to the full extent of the law.

As Bartz pointed out, hospitals are not the optimal setting for most abortion care—in an ideal world, clinics would handle the bulk of patients, while hospitals took care of medically complex, resource-intensive cases. But we do not live in that ideal world. As wait times at clinics across the nation increase, every health-care setting must do what it can.

One thing appears certain: While it is neither practical nor helpful to move the majority of abortion care back into a hospital setting, hospitals and the physicians who work in them cannot allow clinics and abortion funds to continue shouldering the social, legal, medical, and financial burden of this fight alone.