by Teddy Rosenbluth, The Charlotte Observer

Credit: Unsplash/CC0 Public Domain

Dr. Nicole Teal was working a night shift in September 2022, when a patient came into UNC Medical Center's labor and delivery unit with a particularly dangerous set of symptoms.

Her blood pressure had suddenly spiked. Her platelets were decreasing. Liver enzymes in her blood were rising. She had the hallmarks of severe preeclampsia, one of the leading causes of death for pregnant women.

"I don't want to threaten my life," Teal recalled the patient telling her. "I'd like an abortion."

After four years of medical school, four years of training to become an OB-GYN and now, nearly three years of specialized maternal-fetal medicine training, Teal knew her patient's instincts were in line with medical recommendations.

At 21 weeks, the fetus was unlikely to survive outside the womb, and without intervention, the patient was at risk of "catastrophic" complications like seizures, strokes and renal failure.

But about a month earlier, the U.S. Supreme Court's decision to overrule Roe v. Wade allowed a 20-week abortion ban to take effect in North Carolina. To end the pregnancy, Teal would have to be able to show it was an imminent risk to her patient's life.

The patient did not yet meet that legal bar. So they waited.

"I watched her for several days until she got sick enough—until her organs were starting to fail," she said. "Then we could provide her abortion."

The following months brought a string of similar cases. Even though she split her time between research and clinical work, Teal estimated North Carolina law forced her to delay care about once every two months. She imagined it would become even more common once the state's newest abortion law, which bans most abortions after 12 weeks, took effect in July.

When Teal's maternal-fetal medicine fellowship ended in June, she was offered what would have been a dream job: a faculty position in UNC's Department of Obstetrics & Gynecology.

She loved her patients and colleagues in North Carolina. She was passionate about her research and had a grant that would fund it for years to come. Her parents lived close enough to Chapel Hill that they could visit their 2-year-old grandson every month.

But Teal couldn't help but replay patient conversations in her mind: My recommendation is to terminate your pregnancy, but I can't do that until you get a little sicker. She remembered their faces, staring back in disbelief.

She accepted a job in San Diego, where there is no gestational limit on abortion.

The News & Observer interviewed several doctors at different stages of their careers—from those in the midst of training to those with well-established medical practices—who plan to take their expertise elsewhere due to the state's new abortion laws.

These are not just doctors who have made abortions a central part of their jobs, though those doctors are leaving, too. They are primary care providers. They are rural obstetricians. The kinds of doctors that the state has a critical shortage of.

It's too soon to know how many doctors will choose to leave, or how many will avoid moving to the state in the first place.

But in North Carolina—where almost a quarter of counties lack a single OB-GYN and more than 90% of counties are considered "primary care shortage areas"—losing a handful of doctors would have major consequences for the patients they leave behind.

A critical shortage

A few hours before his shift ends, Dr. Alan Rosenbaum begins transferring his patients to other hospitals.

On the Western edge of North Carolina, where Rosenbaum is often contracted to fill in for short-staffed labor and delivery units, there is such a dearth of obstetricians that some hospitals have no choice but to shut down the ward after he drives home to Cary.

"If there's no doctor, you can't have a labor and delivery unit," he said.

Newly postpartum patients are loaded into ambulances beside their tiny, pink babies.

Sicker women leave in helicopters.

Patients who arrive too late are told to drive to the next nearest hospital, which is sometimes 40 minutes away, if they want to see an OB-GYN.

Rosenbaum finds his contract-work in rural hospitals fulfilling. The extra income helps his family pay off $250,000 in medical school debt. But North Carolina's newest abortion law has made it too risky for him to continue.

Even though Rosenbaum does not perform elective abortions, he imagined the professional and ethical dilemmas the new legislation would create.

If a pregnant woman arrived severely hemorrhaging, could he clear the fetus from her uterus to stop the bleeding? Or would he have to wait until she got sicker, lost more blood, before the situation fit lawmakers' definition of a "medical emergency."

Hours after the governor's veto of the abortion bill was overridden by Republican lawmakers, Rosenbaum applied for a medical license in Virginia, where he will soon work shifts instead of North Carolina.

"I really do find fulfillment and enjoyment caring for the women in North Carolina," he said. "But the people of Virginia are good people too, right? Why would I not choose the location where there's less risk of a bad outcome?"

Obstetricians are a strained resource in North Carolina.

Twenty-one of 100 counties are considered "maternity care deserts," which means they have no hospitals providing obstetric care, no birth centers, no OB-GYN and no certified nurse midwives. Seventeen more counties are considered "low access," a designation given to areas with limited services and a high proportion of uninsured women.

OB-GYNs who have completed additional specialty training, like maternal-fetal medicine doctors, are in even higher demand. In North Carolina, Teal almost always double-booked her appointment slots to fit in patients who had traveled from across the state to see her, she said.

These shortages are concentrated in rural parts of the state, where recruiting doctors is difficult.

When Dr. Katie Borders has an OB-GYN opening at her practice in Shelby—a small town about an hour west of Charlotte—she said it often takes more than a year to fill. In the Outer Banks, it could take up to two years, said Dr. Daniel Dwyer, an OB-GYN in Nags Head.

Rosenbaum doubts the abortion restrictions will cause a mass exodus of doctors—he knows state laws are just one factor in a complicated decision about where to live and practice.

But for the rural hospitals where he used to work, losing just one physician could mean the difference between life and death.

"Even if statistically it's like a rounding error, it's not a rounding error for that woman who's having an emergency at a hospital with no OB-GYN," he said.

'I'm not going to be able to train'

About two weeks after legislators passed North Carolina's new abortion law, Dr. Sheridan Finnie received the email she had been dreading: Her clinical rotation at an abortion clinic had been canceled.

Finnie, a family medicine resident in the Triangle, was scheduled to spend part of July in Chapel Hill's Planned Parenthood clinic, learning how to perform elective abortions. The clinic had to pause those rotations while they adjusted to the substantial new abortion restrictions, summer trainees were told in an email.

"Holy s—," she remembered texting her husband. "I'm not going to be able to train."

That week, Finnie sent off a flurry of frantic messages. She probed her network of doctor friends for potential openings. She solicited advice from faculty in her program ("I'm scrambling to pull some opportunities together," she emailed one doctor).

She even left a message at a Planned Parenthood clinic in Utica, New York, near where her parents lived.

Finnie did not have ambitions to become a full-time abortion provider—she wanted to be a primary care provider. But to her, becoming trained to perform abortions was just as important as learning to manage her patients' hypertension or diabetes.

In fact, part of the reason she chose to do her residency in the Triangle was because of the easy access to abortion training (in the South, these rotations are typically less competitive because they are less sought after by trainees, she said). Finnie never imagined she would be pleading for opportunities hundreds of miles across the country.

She isn't sure she would train in North Carolina if she could do it all again, she said.

As North Carolina's hospitals gear up for this year's residency application cycle, program directors fear prospective doctors will make similar calculations about their training.

In the last application cycle, which ended months before the state's newest abortion law was introduced, prospective residents were already asking questions about the state's political landscape, said Dr. Beverly Gray, the immediate past director of Duke's OB-GYN residency program.

What abortion laws were in the pipeline? How would the program make sure they could still train if restrictions passed?

"They were being thoughtful about it in a way I have not seen in previous years," Gray said.

Recent data suggests that abortion laws play a large role in where doctors choose to train.

In states where abortion had been totally banned, applications to OB-GYN residency programs fell by more than 10% compared with the prior year, according to an analysis of data from the 2022-2023 application cycle by the Association of American Medical Colleges.

In states with gestational limits on abortion—which includes North Carolina—applications dropped 6.4%.

This is significant for patients, Gray said, because doctors who train in the state often settle down nearby. More than half of doctors stay in the state where they complete their residency, according to another survey from the AAMC.

Gray fears that new abortion restrictions will not only shrink the funnel of doctors into North Carolina but also make the state a less appealing place for residents to stay after they graduate.

This is true for Finnie and her husband, who is also in residency.

More than 3 million North Carolinians live in an area with a shortage of primary care providers, according to federal data. After years of training in the state, Finnie and her husband thought they might settle here; they'd dreamed of joining a practice in a rural area.

The new abortion law changed that.

Finnie had read news reports of Missouri and Texas doctors who were scared to treat ectopic pregnancies and miscarriages because of their own states' abortion restrictions. After spending nearly a decade training to become a doctor, that was not the way she wanted to practice medicine.

"If there were any thoughts of me staying in North Carolina, this has certainly put the kibosh on that," Finnie said. "There's no chance that we're going to stay here."

2023 The Charlotte Observer.
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