A substantial body of research has investigated effects of the Affordable Care Act (ACA) Medicaid expansion, adopted by all but 10 states as of June 2023. Prior KFF reports published in 2020 and 2021 reviewed more than 600 studies and concluded that expansion is linked to gains in coverage, improvement in access and health, and economic benefits for states and providers; these generally positive findings persist even as more recent research considers increasingly complex and specific outcomes. This research provides context for ongoing debates about whether to expand Medicaid in states that have not done so already, where coverage options for many low-income adults are limited and nearly two million individuals fall into a coverage gap.

Medicaid is the largest source of public funding for family planning services—which are a mandatory benefit within the program—and finances 4 in 10 births in the United States, as well as provides prenatal and postpartum coverage. Federal law requires all states, including those that have not expanded Medicaid, to provide Medicaid coverage to pregnant individuals with incomes up to at least 138% of the federal poverty level (FPL). However, coverage options for the pre-pregnancy and postpartum periods vary across states and are more limited in non-expansion states. Nationwide, nearly 900,000 women fall into the coverage gap in non-expansion states.¹ 

This brief updates prior KFF literature reviews by summarizing 40 studies published between April 2021 and June 2023 on the impacts of Medicaid expansion on a range of sexual and reproductive health outcomes, including:

• health insurance coverage before, during, and after pregnancy;
• maternal and infant health access, utilization, and outcomes;
• family planning; and
• HIV care and prevention.

Consistent with prior research, recent studies identify positive effects of Medicaid expansion on coverage rates before, during, and after pregnancy; access to prenatal and postpartum care; birth and postpartum outcomes; use of the most effective contraceptive methods; and HIV screening and outcomes.

Our methodology is consistent with that of prior analyses. We conducted keyword searches of PubMed and other academic/health policy search engines to collect credible studies (published by a journal or by a nonpartisan research organization) on the impacts of the ACA Medicaid expansion. We then reviewed study abstracts to identify relevancy to sexual and reproductive health. Included study findings fall into four topic areas (Figure 1). Within each topic area, we first briefly summarize findings from earlier research (published between January 2014 and March 2021) and then highlight key findings from recent research that add to this body of evidence. For more information about earlier studies, see the 2021 and 2020 literature reviews. For citations from April 2021 through June 2023, see the Bibliography.

Insurance Coverage Before, During, and After Pregnancy

Prior studies overwhelmingly found that expansion increased postpartum coverage rates, as well as coverage prior to and during pregnancy. Although the American Rescue Plan Act of 2021 created a new option to expand postpartum coverage to 12 months via a State Plan Amendment, current federal statute requires that pregnancy-related Medicaid coverage continue through just 60 days. Earlier research indicates that ACA Medicaid expansion has decreased coverage loss after this 60-day period ends: all prior studies that consider rates of insurance coverage after pregnancy find that expansion significantly increased postpartum coverage. Studies also suggest an association between expansion and increased coverage prior to and during pregnancy.

Most recent studies continue to find that expansion is associated with coverage gains in the pre-pregnancy, pregnancy, and postpartum periods. All recent studies that consider the impact of expansion on insurance coverage prior to conception and at birth find coverage gains.^{2 ,3 ,4 ,5}  Also, four studies find increases in coverage during the postpartum period, including one that also found that racial disparities in such coverage decreased.^{6 ,7 ,8 ,9}  One study considered Medicaid coverage post-abortion in Oregon and found a significant increase, as well as significant declines in lapses in enrollment.¹⁰  In contrast, two studies had mixed findings and found that postpartum coverage gains were not significant.^11 ,12 

Maternal and Infant Health: Access, Utilization, and Outcomes

Prior studies found that expansion increased access to health care for pregnant and postpartum women, and some suggested improvements in certain adverse pregnancy outcomes. Studies find that expansion increased access to and utilization of prenatal services—such as medications to treat opioid use disorder (MOUD) during pregnancy—as well as postpartum care. Additionally, all prior studies that consider impacts on maternal mortality or morbidity find significant declines, though findings on the impact of expansion on other health outcomes during pregnancy are mixed. Studies generally suggest an association between expansion and improvements in infant birth outcomes such as low birthweight, but most find no impact on infant mortality or find that improvements in infant mortality were concentrated among non-White infants.

Consistent with previous research, recent studies find that expansion is associated with increased access to and utilization of prenatal and postpartum care. Most studies in this area find that expansion resulted in increased utilization of at least one prenatal or postpartum service.^{13 ,14 ,15 ,16 ,17 ,18 ,19 ,20}  These findings include increased use of services during pregnancy or childbirth, such as receipt of adequate prenatal care (both prior to and during the COVID-19 pandemic) and of MOUD, as well as of services during the postpartum period, such as breast pump claims and treatment for postpartum depression. Additionally, two studies find that Medicaid expansion may have promoted access to obstetrician-gynecologist (OB-GYN) care: by increasing the likelihood that OB-GYN practices have onsite resources to address psychosocial needs, and by facilitating access to intrapartum care for White and Hispanic women living in rural counties with obstetric unit closures.^21 ,22  A smaller number of studies find no impact of expansion on utilization of certain prenatal/postpartum services (such as early prenatal care), nor on access to providers (such as hospital-based obstetric units).^{23 ,24 ,25 ,26 ,27 ,28} 

Recent studies on the impact of expansion on adverse outcomes during pregnancy, birth, or postpartum are mixed. Several studies identify that expansion is associated with improvements in at least one health outcome.^{29 ,30 ,31 ,32 ,33}  These findings include decreased incidence of adverse outcomes prior to pregnancy and at birth:

• Improved pre-pregnancy health outcomes: One study found that expansion was associated with significant declines in self-reported pre-pregnancy depression.³⁴ 
• Improved maternal outcomes at childbirth: Consistent with prior research, one recent study considering maternal morbidity in New York found a significant decrease in incidence, and that this decrease was significantly greater for low- versus high-income women.³⁵ 
• Improved infant outcomes at childbirth: Two studies found that expansion was associated with lower rates of infant mortality (one of which identified a particular impact among Hispanic infants, similar to earlier research).^36 ,37  One study found that expansion decreased the rate of low birth weight among infants born to mothers with hypertension in pregnancy.³⁸  Finally, one study found that expansion reduced racial/ethnic disparities in infant health following rural obstetric unit closures.³⁹ 

However, a similar number of studies find no impact of expansion on certain pregnancy or postpartum health outcomes, including incidences of gestational hypertension/diabetes and of postpartum depressive symptoms.^{40 ,41 ,42 ,43 ,44 ,45 ,46} 

Family Planning

Prior literature reviews indicated that expansion increased utilization of the most effective contraception methods but had little or no effect on overall contraception use. Medicaid is the primary funding source for family planning services for low-income people, with state programs required to cover all prescription contraceptives. Although the literature generally indicates that expansion has had little effect on contraception use overall, numerous studies identify an increased use of the most effective, long-acting reversible contraception (LARC), which includes IUDs and implants.

Recent studies find that expansion increased rates of LARC utilization and may have increased overall contraception use among some populations. Recent studies identify increases in utilization of LARC, short-acting contraception, and overall contraception for certain populations.^{47 ,48 ,49 ,50 ,51 ,52} 

• Increased LARC utilization: Three studies find increased use of LARC: among all Medicaid enrollees, among postpartum individuals, and among sexually active high school students.^53 ,54 ,55 
• Increased short-acting contraception utilization: One study found that physicians in Medicaid expansion states provided significantly more enrollees with short-acting hormonal birth control methods compared to physicians in non-expansion states.⁵⁶ 
• Increased contraception utilization overall (short- and long-acting): One study found a significant increase in the use of any postpartum contraception method, driven by a shift from short-acting and non-prescription contraceptive methods to higher-cost, more effective forms of contraception.⁵⁷  Two studies pointed to increased use of contraceptive services and counseling among Medicaid-enrolled women of reproductive age in Oregon.^58 ,59 

Finally, consistent with earlier research, two studies found no significant impact of expansion on overall contraception use for certain populations (students and postpartum individuals).^60 ,61  Another study found that physicians in expansion and non-expansion states provided similar numbers of enrollees with LARC methods in 2016.⁶² 

A couple of recent studies suggest that increased access to family planning care after expansion may have decreased birth rates and short interpregnancy intervals, but others find no effect on these outcomes. One study found that expansion resulted in an overall decrease in live births among low-income women of reproductive age, particularly among subgroups with historically higher rates of unintended pregnancy (including unmarried, Hispanic, and American Indian and Alaskan Native women).⁶³  Another study found that expansion resulted in a decreased risk of short interpregnancy intervals (less than 12 months between births), which the authors note have a known association with poor maternal and infant health outcomes.⁶⁴  In contrast, three other studies find no impact of expansion on these or similar outcomes, including one study that found no impact on overall rates of early postpartum pregnancies but that such pregnancies did significantly decrease among Black patients.^65 ,66 ,67 

HIV Care and Prevention Outcomes

Prior studies suggest that expansion increased rates of HIV screening as well as health outcomes for those diagnosed with HIV. Prior to the ACA, many people with HIV faced limited access to insurance coverage. Research finds that expansion increased insurance coverage rates among people with or at risk of HIV. Prior studies also indicate that expansion led to increases in HIV test and diagnosis rates despite no change in actual HIV incidence. Finally, studies find that expansion is associated with increased utilization of Pre-Exposure Prophylaxis (PrEP) to prevent HIV and improved quality of care for patients with HIV.

Most recent studies continue to find positive effects of expansion on HIV screening rates and outcomes.⁶⁸  Consistent with prior research, recent studies find an association between expansion and increased rates of HIV testing.^69 ,70  Also, a study found significant coverage gains among women with or at risk of contracting HIV.⁷¹  Two studies on Medicaid expansion and PrEP both found positive impacts. The first found a small but significant increase in the likelihood that men (and transgender or nonbinary individuals) who have sex with men (MSM) were taking PrEP to prevent HIV.⁷²  The second found that Medicaid expansion was associated with a higher share of Google searches for PrEP keywords, potentially indicating an higher awareness of and interest in PrEP due to increased access.⁷³  Finally, a study that following expansion, people with HIV experienced a significant increase in linkages to care after diagnosis, but no change in viral suppression of HIV (which the authors note could be in part because of state variation in Medicaid coverage policies for people with HIV).⁷⁴ 

Emerging Research

A small number of additional emerging studies include findings on:

Abortion: The Hyde Amendment blocks states from using federal funds to pay for abortion services under Medicaid in most instances.⁷⁵  However, 17 states (all of which have expanded Medicaid) use state-only Medicaid funds to cover all or most medically accessible abortions. A recent study found no impact of Medicaid expansion on the abortion rate nationwide, though the authors note that this analysis was exploratory and that future research on expansion’s impact on abortions is necessary.⁷⁶  Research in this area may continue particularly as abortion access across states continues to evolve following the Dobbs v. Jackson Women’s Health Organization decision.

LGBTQ+ individuals: Earlier research found gains in Medicaid coverage among lesbian, gay, and bisexual individuals following expansion. Similarly, one recent study found that following Medicaid expansion, overall insurance coverage rates increased for low-income individuals in same-sex couples, with larger gains for women versus men. The study also noted no significant impact on the likelihood of being employed for either low-income men or women in same-sex couples.⁷⁷  Another study found that Medicaid expansion was associated with higher odds of having health coverage among transgender adults.⁷⁸ 

Taken together, the 40 new studies summarized in this brief add to the body of prior research finding positive effects of expansion on sexual and reproductive health. This research provides context for ongoing debates about whether to expand Medicaid in states that have not done so already. As states unwind the pandemic-era continuous enrollment provision in 2023, many individuals who qualified for Medicaid through the pregnancy pathway during the pandemic are at risk of losing Medicaid coverage. These individuals will have more coverage options in states that have expanded Medicaid. Looking ahead, future research may consider the impacts of expansion against the backdrop of evolving national and state landscapes around Medicaid eligibility as well as access to reproductive health care.

Bibliography, April 2021 to June 2023

Bibliography (.pdf)

1. KFF analysis of 2021 American Community Survey (ACS). ↩︎
2. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
3. Jean Guglielminotti, Ruth Landau, and Guohua Li, “The 2014 New York State Medicaid Expansion and Severe Maternal Morbidity During Delivery Hospitalizations,” Anesthesia & Analgesia 133 no. 2 (August 2021): 340-348, https://doi.org/10.1213/ANE.0000000000005371 ↩︎
4. Claire E. Margerison, Katlyn Hettinger, Robert Kaestner, Sidra Goldman-Mellor, and Danielle Gartner, “Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health,” Health Affairs 40 no. 10 (October 2021), https://doi.org/10.1377/hlthaff.2021.00776 ↩︎
5. Bradley Corallo and Brittni Frederiksen, How Does the ACA Expansion Affect Medicaid Coverage Before and During Pregnancy? (Washington, DC: KFF, October 2022), https://modern.kff.org/medicaid/issue-brief/how-does-the-aca-expansion-affect-medicaid-coverage-before-and-during-pregnancy/ ↩︎
6. Lindsey Rose Bullinger, Kosali Simon, and Brownsyne Tucker Edmonds, “Coverage Effects of the ACA’s Medicaid Expansion on Adult Reproductive-Aged Women, Postpartum Mothers, and Mothers with Older Children,” Maternal and Child Health Journal 26 (March 2022): 1104-1114, https://doi.org/10.1007/s10995-022-03384-8 ↩︎
7. Maria Steenland, Ira Wilson, and Kristen Matteson, “Association of Medicaid Expansion in Arkansas With Postpartum Coverage, Outpatient Care, and Racial Disparities,” JAMA Health Forum 2 no. 12 (December 2021), https://doi.org/10.1001/jamahealthforum.2021.4167 ↩︎
8. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
9. Bradley Corallo, Jennifer Tolbert, Heather Saunders, and Brittni Frederiksen, Medicaid Enrollment Patterns During the Postpartum Year (Washington, DC: KFF, July 2022), https://modern.kff.org/medicaid/issue-brief/medicaid-enrollment-patterns-during-the-postpartum-year/ ↩︎
10. Susannah E. Gibbs and S. Marie Harvey, “Postabortion Medicaid Enrollment and the Affordable Care Act Medicaid Expansion in Oregon,” Journal of Women’s Health 31 no. 1 (January 2022): 55-62, https://doi.org/10.1089/jwh.2020.8941 ↩︎
11. Claire E. Margerison, Katlyn Hettinger, Robert Kaestner, Sidra Goldman-Mellor, and Danielle Gartner, “Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health,” Health Affairs 40 no. 10 (October 2021), https://doi.org/10.1377/hlthaff.2021.00776 ↩︎
12. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
13. Summer Hawkins, Krisztina Horvath, Alice Noble, and Christopher Baum, “ACA and Medicaid Expansion Increased Breast Pump Claims and Breastfeeding for Women with Public and Private Insurance,” Women’s Health Issues 32 no. 2 (March 2022): 114-121, https://www.whijournal.com/article/S1049-3867(21)00158-4/fulltext ↩︎
14. Ian Everitt et al., “Association of State Medicaid Expansion Status With Hypertensive Disorders of Pregnancy in a Singleton First Live Birth,” Circulation: Cardiovasucular Quality and Outcomes 15 no. 1 (January 2022), https://doi.org/10.1161/CIRCOUTCOMES.121.008249 ↩︎
15. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
16. Maria Steenland, Ira Wilson, and Kristen Matteson, “Association of Medicaid Expansion in Arkansas With Postpartum Coverage, Outpatient Care, and Racial Disparities,” JAMA Health Forum 2 no. 12 (December 2021), https://doi.org/10.1001/jamahealthforum.2021.4167 ↩︎
17. Sugy Choi et al., “Estimating The Impact on Initiating Medications for Opioid Use Disorder of State Policies Expanding Medicaid and Prohibiting Substance Use During Pregnancy,” Drug and Alcohol Dependence 129 pt. A (December 2021), https://www.sciencedirect.com/science/article/abs/pii/S0376871621006578 ↩︎
18. Maria Steenland and Amal Trivedi, “Association of Medicaid Expansion With Postpartum Depression Treatment in Arkansas,” JAMA Health Forum 4 no. 2 (February 2023), https://doi.org/10.1001/jamahealthforum.2022.5603 ↩︎
19. Pinka Chatterji, Hanna Glenn, Sara Markowitz, and Jennifer Karas Montez, ACA Medicaid Expansions and Maternal Morbidity (National Bureau of Economic Research, Working Paper No. 30770, December 2022), https://www.nber.org/papers/w30770 ↩︎
20. Hyunjung Lee and Gopal Singh, “The Differential Impact of the COVID-19 Pandemic on Prenatal Care Utilization Among US Women by Medicaid Expansion and Race and Ethnicity,” Journal of Public Health Management and Practice Epub ahead of print (December 2022), https://doi.org/10.1097/PHH.0000000000001698 ↩︎
21. Gabriela Weigel, Brittni Frederiksen, Usha Ranji, and Alina Salganicoff, “Screening and Intervention for Psychosocial Needs by U.S. Obstetrician-Gynecologists,” Journal of Women’s Health 31 no. 6 (June 2022): 887-894, https://doi.org/10.1089/jwh.2021.0236 However, this study found no significant impact of expansion on the likelihood that OB-GYN practices report actually screening all patients for these needs. ↩︎
22. Pinka Chatterji, Chun-Yu Ho, and Xue Wu, Obstetric Unit Closures and Racial/Ethnic Disparity in Health (National Bureau of Economic Research, Working Paper No. 30986, February 2023), https://www.nber.org/papers/w30986 ↩︎
23. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
24. Claire Margerison, Robert Kaestner, Jiajia Chen, and Colleen MacCallum-Bridgers, “Impacts of Medicaid Expansion Before Conception on Prepregnancy Health, Pregnancy Health, and Outcomes,” American Journal of Epidemiology 190 no. 8 (August 2021): 1488-1498, https://doi.org/10.1093/aje/kwaa289 ↩︎
25. Maria Steenland, Ira Wilson, and Kristen Matteson, “Association of Medicaid Expansion in Arkansas With Postpartum Coverage, Outpatient Care, and Racial Disparities,” JAMA Health Forum 2 no. 12 (December 2021), https://doi.org/10.1001/jamahealthforum.2021.4167 ↩︎
26. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
27. Gabriela Weigel, Brittni Frederiksen, Usha Ranji, and Alina Salganicoff, “Screening and Intervention for Psychosocial Needs by U.S. Obstetrician-Gynecologists,” Journal of Women’s Health 31 no. 6 (June 2022): 887-894, https://doi.org/10.1089/jwh.2021.0236 ↩︎
28. Caitlin Carroll, Julia Interrante, Jamie Daw, and Katy Backes Kozhimannil, “Association Between Medicaid Expansion and Closure of Hospital-Based Obstetric Services,” Health Affairs 41 no. 4 (April 2022), https://doi.org/10.1377/hlthaff.2021.01478 ↩︎
29. Jean Guglielminotti, Ruth Landau, and Guohua Li, “The 2014 New York State Medicaid Expansion and Severe Maternal Morbidity During Delivery Hospitalizations,” Anesthesia & Analgesia 133 no. 2 (August 2021): 340-348, https://doi.org/10.1213/ANE.0000000000005371 ↩︎
30. Joanne Constantin and George Wehby, “Effects of Recent Medicaid Expansions on Infant Mortality by Race and Ethnicity,” American Journal of Preventive Medicine 64 no. 3 (March 2023): 377-384, https://www.ajpmonline.org/article/S0749-3797(22)00498-6/fulltext ↩︎
31. Claire E. Margerison, Katlyn Hettinger, Robert Kaestner, Sidra Goldman-Mellor, and Danielle Gartner, “Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health,” Health Affairs 40 no. 10 (October 2021), https://doi.org/10.1377/hlthaff.2021.00776 ↩︎
32. Ian Everitt et al., “Association of State Medicaid Expansion Status With Hypertensive Disorders of Pregnancy in a Singleton First Live Birth,” Circulation: Cardiovasucular Quality and Outcomes 15 no. 1 (January 2022), https://doi.org/10.1161/CIRCOUTCOMES.121.008249 ↩︎
33. Maria Steenland and Laura Wherry, “Medicaid Expansion Led To Reductions In Postpartum Hospitalizations,” Health Affairs 42 no. 1 (January 2023): 18-25, https://doi.org/10.1377/hlthaff.2022.00819 ↩︎
34. Claire E. Margerison, Katlyn Hettinger, Robert Kaestner, Sidra Goldman-Mellor, and Danielle Gartner, “Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health,” Health Affairs 40 no. 10 (October 2021), https://doi.org/10.1377/hlthaff.2021.00776 ↩︎
35. Jean Guglielminotti, Ruth Landau, and Guohua Li, “The 2014 New York State Medicaid Expansion and Severe Maternal Morbidity During Delivery Hospitalizations,” Anesthesia & Analgesia 133 no. 2 (August 2021): 340-348, https://doi.org/10.1213/ANE.0000000000005371 In contrast, a national study (Chatterji et al. 2022), cited below, found no significant impact on severe maternal morbidity, but did not limit this analysis by income. ↩︎
36. Joanne Constantin and George Wehby, “Effects of Recent Medicaid Expansions on Infant Mortality by Race and Ethnicity,” American Journal of Preventive Medicine 64 no. 3 (March 2023): 377-384, https://www.ajpmonline.org/article/S0749-3797(22)00498-6/fulltext ↩︎
37. Jessian Munoz, “Preterm Birth and Foetal-Neonatal Death Rates Associated With the Affordable Care Act Medicaid Expansion (2014–19),” Journal of Public Health 45 no. 1 (March 2023): 99–101, https://doi.org/10.1093/pubmed/fdab377 ↩︎
38. Ian Everitt et al., “Association of State Medicaid Expansion Status With Hypertensive Disorders of Pregnancy in a Singleton First Live Birth,” Circulation: Cardiovasucular Quality and Outcomes 15 no. 1 (January 2022), https://doi.org/10.1161/CIRCOUTCOMES.121.008249 ↩︎
39. Pinka Chatterji, Chun-Yu Ho, and Xue Wu, Obstetric Unit Closures and Racial/Ethnic Disparity in Health (National Bureau of Economic Research, Working Paper No. 30986, February 2023), https://www.nber.org/papers/w30986 ↩︎
40. Joanne Constantin and George Wehby, “Effects of Recent Medicaid Expansions on Infant Mortality by Race and Ethnicity,” American Journal of Preventive Medicine 64 no. 3 (March 2023): 377-384, https://www.ajpmonline.org/article/S0749-3797(22)00498-6/fulltext ↩︎
41. Claire E. Margerison, Katlyn Hettinger, Robert Kaestner, Sidra Goldman-Mellor, and Danielle Gartner, “Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health,” Health Affairs 40 no. 10 (October 2021), https://doi.org/10.1377/hlthaff.2021.00776 ↩︎
42. Ian Everitt et al., “Association of State Medicaid Expansion Status With Hypertensive Disorders of Pregnancy in a Singleton First Live Birth,” Circulation: Cardiovasucular Quality and Outcomes 15 no. 1 (January 2022), https://doi.org/10.1161/CIRCOUTCOMES.121.008249 ↩︎
43. Claire Margerison, Robert Kaestner, Jiajia Chen, and Colleen MacCallum-Bridgers, “Impacts of Medicaid Expansion Before Conception on Prepregnancy Health, Pregnancy Health, and Outcomes,” American Journal of Epidemiology 190 no. 8 (August 2021): 1488-1498, https://doi.org/10.1093/aje/kwaa289 ↩︎
44. Anna Austin, Rebeccah Sokol, and Caroline Rowland, “Medicaid Expansion and Postpartum Depressive Symptoms: Evidence From the 2009-2018 Pregnancy Risk Assessment Monitoring System Survey,” Annals of Epidemiology 68 (April 2022): 9-15, https://www.sciencedirect.com/science/article/abs/pii/S1047279721003537 ↩︎
45. Maria Steenland and Laura Wherry, “Medicaid Expansion Led To Reductions In Postpartum Hospitalizations,” Health Affairs 42 no. 1 (January 2023): 18-25, https://doi.org/10.1377/hlthaff.2022.00819 ↩︎
46. Pinka Chatterji, Hanna Glenn, Sara Markowitz, and Jennifer Karas Montez, ACA Medicaid Expansions and Maternal Morbidity (National Bureau of Economic Research, Working Paper No. 30770, December 2022), https://www.nber.org/papers/w30770 ↩︎
47. Lydia Pace, Indrani Saran, and Summer Sherburne Hawkins, “Impact of Medicaid Eligibility Changes on Long-acting Reversible Contraception Use in Massachusetts and Maine,” Medical Care 60 no. 2 (February 2022): 119-124, https://doi.org/10.1097/MLR.0000000000001666 ↩︎
48. Erica L. Eliason, Amanda Spishak-Thomas, and Maria W. Steenland, “Association of the Affordable Care Act Medicaid Expansions with Postpartum Contraceptive Use and Early Postpartum Pregnancy,” Contraception 113 (September 2022): 42-48, https://www.contraceptionjournal.org/article/S0010-7824(22)00060-9/fulltext ↩︎
49. Greta Kilmer et al., “Medicaid Expansion and Contraceptive Use Among Female High-School Students,” American Journal of Preventive Medicine 63 no. 4 (October 2022): 592-602, https://www.ajpmonline.org/article/S0749-3797(22)00244-6/fulltext ↩︎
50. Mandar Bodas et al., “Association of Primary Care Physicians’ Individual- and Community-Level Characteristics With Contraceptive Service Provision to Medicaid Beneficiaries,” JAMA Health Forum 4 no. 3 (March 2023), https://doi.org/10.1001/jamahealthforum.2023.0106 ↩︎
51. Susannah E. Gibbs, S. Marie Harvey, Annie Larson, Jangho Yoon, and Jeff Luck, “Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program,” Journal of Women’s Health 30 no. 5 (May 2021): 750-757, https://doi.org/10.1089/jwh.2020.8351 ↩︎
52. Mandana Masoumirad, S. Marie Harvey, Linh N. Bui, and Jangho Yoon, “Use of Sexual and Reproductive Health Services Among Women Living in Rural and Urban Oregon: Impact of the Affordable Care Act Medicaid Expansion,” Journal of Women’s Health 32 no. 3 (March 2023): 300-310, https://doi.org/10.1089/jwh.2022.0308 ↩︎
53. Lydia Pace, Indrani Saran, and Summer Sherburne Hawkins, “Impact of Medicaid Eligibility Changes on Long-acting Reversible Contraception Use in Massachusetts and Maine,” Medical Care 60 no. 2 (February 2022): 119-124, https://doi.org/10.1097/MLR.0000000000001666 ↩︎
54. Erica L. Eliason, Amanda Spishak-Thomas, and Maria W. Steenland, “Association of the Affordable Care Act Medicaid Expansions with Postpartum Contraceptive Use and Early Postpartum Pregnancy,” Contraception 113 (September 2022): 42-48, https://www.contraceptionjournal.org/article/S0010-7824(22)00060-9/fulltext ↩︎
55. Greta Kilmer et al., “Medicaid Expansion and Contraceptive Use Among Female High-School Students,” American Journal of Preventive Medicine 63 no. 4 (October 2022): 592-602, https://www.ajpmonline.org/article/S0749-3797(22)00244-6/fulltext ↩︎
56. Mandar Bodas et al., “Association of Primary Care Physicians’ Individual- and Community-Level Characteristics With Contraceptive Service Provision to Medicaid Beneficiaries,” JAMA Health Forum 4 no. 3 (March 2023), https://doi.org/10.1001/jamahealthforum.2023.0106 ↩︎
57. Erica L. Eliason, Amanda Spishak-Thomas, and Maria W. Steenland, “Association of the Affordable Care Act Medicaid Expansions with Postpartum Contraceptive Use and Early Postpartum Pregnancy,” Contraception 113 (September 2022): 42-48, https://www.contraceptionjournal.org/article/S0010-7824(22)00060-9/fulltext ↩︎
58. Susannah E. Gibbs, S. Marie Harvey, Annie Larson, Jangho Yoon, and Jeff Luck, “Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program,” Journal of Women’s Health 30 no. 5 (May 2021): 750-757, https://doi.org/10.1089/jwh.2020.8351 ↩︎
59. Mandana Masoumirad, S. Marie Harvey, Linh N. Bui, and Jangho Yoon, “Use of Sexual and Reproductive Health Services Among Women Living in Rural and Urban Oregon: Impact of the Affordable Care Act Medicaid Expansion,” Journal of Women’s Health 32 no. 3 (March 2023): 300-310, https://doi.org/10.1089/jwh.2022.0308 ↩︎
60. Greta Kilmer et al., “Medicaid Expansion and Contraceptive Use Among Female High-School Students,” American Journal of Preventive Medicine 63 no. 4 (October 2022): 592-602, https://www.ajpmonline.org/article/S0749-3797(22)00244-6/fulltext ↩︎
61. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
62. Mandar Bodas et al., “Association of Primary Care Physicians’ Individual- and Community-Level Characteristics With Contraceptive Service Provision to Medicaid Beneficiaries,” JAMA Health Forum 4 no. 3 (March 2023), https://doi.org/10.1001/jamahealthforum.2023.0106 ↩︎
63. Erica L. Eliason, Jamie R. Daw, and Heidi L. Allen, “Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age,” Journal of Women’s Health 31 no. 7 (July 2022): 949-956, https://doi.org/10.1089/jwh.2021.0451 ↩︎
64. Kriya S. Patel, Juliana Bakk, Meredith Pensak, Emily DeFranco, “Influence of Medicaid Expansion on Short Interpregnancy Interval Rates in the United States,” American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine 3 no. 6 (November 2021), https://www.ajogmfm.org/article/S2589-9333(21)00179-8/fulltext ↩︎
65. Erica L. Eliason, Amanda Spishak-Thomas, and Maria W. Steenland, “Association of the Affordable Care Act Medicaid Expansions with Postpartum Contraceptive Use and Early Postpartum Pregnancy,” Contraception 113 (September 2022): 42-48, https://www.contraceptionjournal.org/article/S0010-7824(22)00060-9/fulltext ↩︎
66. Danielle Gartner, Robert Kaestner, and Claire Margerison, “Impacts of the Affordable Care Act’s Medicaid Expansion on Live Births,” Epidemiology 33 no. 3 (May 2022): 406-414, https://doi.org/10.1097/EDE.0000000000001462 ↩︎
67. Can Liu et al., “Impact of Medicaid Expansion on Interpregnancy Interval,” Womens Health Issues 32 no. 3 (May 2022): 226-234, https://www.whijournal.com/article/S1049-3867(21)00190-0/fulltext ↩︎
68. Consistent with prior analysis, note that study findings on screening and outcomes related to HPV, as well as gynecological cancer generally, are included in our discussion of research on the impact of expansion on cancer-related outcomes. ↩︎
69. Suhang Song and James Kucik, “Trends in the Impact of Medicaid Expansion on the Use of Clinical Preventive Services,” American Journal of Preventive Medicine 62 no. 5 (May 2022): 752-762, https://www.ajpmonline.org/article/S0749-3797(21)00595-X/fulltext ↩︎
70. Toni Romero and Branco Ponomariov, “The Effect of Medicaid Expansion on Access to Healthcare, Health Behaviors and Health Outcomes Between Expansion and Non-Expansion States,” Evaluation and Program Planning Epub ahead of print (May 2023), https://doi.org/10.1016/j.evalprogplan.2023.102304 ↩︎
71. Andrew Edmonds et al., “Impacts of Medicaid Expansion on Health Insurance and Coverage Transitions among Women with or at Risk for HIV in the United States,” Womens Health Issues 32 no. 5 (September-October 2022): 450-460, https://www.whijournal.com/article/S1049-3867(22)00027-5/fulltext ↩︎
72. Pedro Botti Carneiro et al., “Demographic, Clinical Guideline Criteria, Medicaid Expansion and State of Residency: a Multilevel Analysis of PrEP Use on a Large US Sample,” BMJ Open 12 no. 2 (February 2022), https://bmjopen.bmj.com/content/12/2/e055487.info ↩︎
73. Bita Fayaz Farkhad, Mohammadreza Nazari, Man-pui Sally Chan, and Dolores Albarracín, “State Health Policies and Interest in PrEP: Evidence from Google Trends,” AIDS Care 34 no. 3 (2022): 331-339, https://doi.org/10.1080/09540121.2021.1934381 ↩︎
74. J. Logan et al., “HIV Care Outcomes in Relation to Racial Redlining and Structural Factors Affecting Medical Care Access Among Black and White Persons with Diagnosed HIV—United States, 2017,” AIDS and Behavior 26 (March 2022): 2941–2953, https://doi.org/10.1007/s10461-022-03641-5 ↩︎
75. The Hyde amendment includes exceptions for pregnancies that are the result of rape, incest, or if the pregnant person’s life is in danger. ↩︎
76. In particular, the abortion analysis was not restricted to women with Medicaid-eligible incomes and was not limited to only states that cover abortions in Medicaid. Erica L. Eliason, Jamie R. Daw, and Heidi L. Allen, “Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age,” Journal of Women’s Health 31 no. 7 (July 2022): 949-956, https://doi.org/10.1089/jwh.2021.0451 ↩︎
77. Samuel Mann et al., “Effects of the Affordable Care Act’s Medicaid Expansion on Health Insurance Coverage for Individuals in Same-sex Couples,” Health Services Research 58 no. 3 (June 2023): 612-621, https://doi.org/10.1111/1475-6773.14128 ↩︎
78. Nguyen Tran, Kellan Baker, Elle Lett, and Ayden Scheim, “State-Level Heterogeneity in Associations Between Structural Stigma and Individual Health Care Access: A Multilevel Analysis of Transgender Adults in the United States,” Journal of Health Services Research & Policy 28 no. 2 (April 2023): 109-118, https://doi.org/10.1177/13558196221123413 ↩︎

Introduction

One year ago, the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade and opened the door for states to ban or severely restrict the availability of abortion care. Today, people seeking abortion in large swaths of the country must travel to other states to get abortion services or obtain medication abortion through self-managed or other means. In many states, abortion is not banned, but laws impose gestational limits and other restrictions that limit access to abortion. This has left large parts of the U.S., particularly in the South and Southeast, without meaningful abortion access. In the states where abortion remains available under most circumstances, abortion providers have had to take on additional patients traveling to their states to get an abortion. Furthermore, the situation in many states remains uncertain, with new bans being implemented that are often followed by legal challenges creating a complicated landscape to navigate for patients and clinicians, particularly those who provide services to pregnant people.

To understand the impact of the changing abortion landscape on clinical care, KFF conducted a nationally representative survey of office-based OBGYNs practicing in the United States who spend the majority of their working hours (60% or more) in direct patient care and provide sexual and reproductive health care to at least 10% of patients. The survey was fielded from March 17 to May 18, 2023, and responses were received from 569 OBGYNs. This survey examines the provision of sexual and reproductive health care provided by OBGYNs before and after the Dobbs decision, comparing the experiences of OBGYNs practicing in states where abortion is fully banned, states with gestational restrictions, and states where abortion remains available under most circumstances. All differences highlighted in the text of this report are statistically significant.

Key Findings

Abortion Access and Constraints on Care Since Dobbs

• Since the Dobbs decision, half of OBGYNs practicing in states where abortion is banned say they have had patients in their practice who were unable to obtain an abortion they sought. This is the case for one in four (24%) office-based OBGYNs nationally.
• Nationally, one in five office-based OBGYNs (20%) report they have personally felt constraints on their ability to provide care for miscarriages and other pregnancy-related medical emergencies since the Dobbs decision. In states where abortion is banned, this share rises to four in ten OBGYNs (40%).
• Four in ten OBGYNs nationally (44%), and six in ten practicing in states where abortion is banned or where there are gestational limits, say their decision-making autonomy has become worse since the Dobbs ruling. Over a third of OBGYNs nationally (36%), and half practicing in states where abortion is banned (55%) or where there are gestational limits (47%), say their ability to practice within the standard of care has become worse.
• Most OBGYNs (68%) say the ruling has worsened their ability to manage pregnancy-related emergencies. Large shares also believe that the Dobbs decision has worsened pregnancy-related mortality (64%), racial and ethnic inequities in maternal health (70%) and the ability to attract new OBGYNs to the field (55%).

Abortion Policies and Concern About Legal Risk

• Two-thirds of OBGYNs nationally (68%) say they understand the circumstances under which abortion is legal in the state they practice very well. However, among OBGYNs in states where abortion is restricted by gestational limits the share is lower (45%) compared to those practicing in states where abortion is available under most circumstances (79%) or banned (68%).
• Over four in ten (42%) OBGYNs report that they are very or somewhat concerned about their own legal risk when making decisions about patient care and the necessity of abortion. This rises to more than half of OBGYNs practicing in states with gestational limits (59%) and abortion bans (61%).
• Eight in ten OBGYNs approve of a recent policy change from the FDA that allows certified pharmacies to dispense medication abortion pills.

Abortion Services

• Nearly one in five (18%) officed-based OBGYNs nationally say that they are providing abortion services after the Dobbs About three in ten OBGYNs (29%) practicing in states where abortion is available under most circumstances offer abortion care, compared to just 10% in states with gestational restrictions. There were already large differences between states prior to the Supreme Court’s ruling. Many of the states that have abortion restrictions today had these or similar restrictions in place prior to the Dobbs decision.
• Nationally, 14% of OBGYNs say they provide in-person medication abortions, but only 5% say they provide telehealth medication abortions.
• In states where abortion is banned, essentially no OBGYNs offer abortions, except under very limited circumstances. Additionally, nearly half (48%) of OBGYNs in these states only offer information, such as online resources, to help patients seek out abortion services on their own, but 30% do not even offer their patients referrals to another clinician or any information about abortion.

Contraception

• More than half (55%) of OBGYNs nationally say they have seen an increase in the share of patients seeking some form of contraception since the Dobbs ruling, particularly sterilization (43%) and IUDs and implants (47%).
• Nearly all OBGYNs offer their patients some form of contraceptive care, but only 29% make all methods of contraception available to their patients, including all three methods of emergency contraception (copper intrauterine device (IUD), ulipristal acetate/Ella, and levonorgestrel/Plan B).
• Only one-third of OBGYNs (34%) prescribe or provide all three methods of emergency contraception and one in seven (15%) do not provide any methods of emergency contraception to their patients. A quarter of OBGYNS (25%) only prescribe or provide Plan B, which is available over the counter.
• Availability of care via telehealth expanded greatly after the onset of the COVID-19 pandemic. Today, almost seven in ten OBGYNs (69%) nationally say they provide at least some care via telehealth.

Findings

ABORTION SERVICES

Provision of Abortion by U.S. OBGYNs

The KFF 2023 National OBGYN Survey finds one in five office-based OBGYNs (21%) say they provided any type of abortion prior to the Dobbs decision, which is statistically unchanged from the 18% that say they provide abortion services after the Dobbs decision.

Nationally, just over one in ten office-based OBGYNs (14%) provide in-person medication abortions, 13% provide aspiration abortions, 12% provide dilation and evacuation abortions, and only 5% provide telehealth medication abortions post-Dobbs (Figure 1).

The survey also looks at OBGYNs in states with very different policies on abortion access. Some states have outright banned abortion since the Dobbs ruling, some have limits on abortions between 6- and 22-weeks gestation, and in some states, abortion is largely available under most circumstances. Not surprisingly, there are substantial differences in the provision of abortion services depending on state abortion policies today, and there were already large differences between states prior to the Supreme Court’s ruling.

Many of the states that have gestational limits and bans now already had severe restrictions in place prior to the Dobbs ruling, which greatly limited abortion access and provision. As a result, just 12% of OBGYNs in states with gestational restrictions provided abortions before the Dobbs decision, compared to 30% in states where abortion remains available under most circumstances. The shares are similar today, with 29% of OBGYNs in states where abortion is available under most circumstances offering abortion care, compared to just 10% in states with gestational restrictions.

In states where abortion is now banned there were not sufficient shares of OBGYNs providing abortion services pre- and post-Dobbs to report. The shares of OBGYNs who perform abortions did not change substantially after the Dobbs decision in any of the state groupings (Table 1). In states with gestational limits only 6% of OBGYNs provide medication abortions and 9% provide abortion procedures. In contrast, in states where abortion is available under most circumstances, one quarter (23%) of OBGYNs say they provide medication abortions and abortion procedures (24%).

Many OBGYNs say they will refer their patients to another clinician for abortion services but don’t provide abortions themselves. Nearly three in ten OBGYNs say they do not provide nor refer their patients to abortion services, but they do share information about resources (e.g., a link to a website such as Abortion Finder or Plan C) (25-29% across different types of abortions). For most abortion procedures and in-person medication abortions, one in eight OBGYNs (12-13%) do not provide, refer, or offer information to their patients about abortion services. One in five (21%) do not provide, refer, or offer information to their patients about telehealth medication abortions (Figure 2).

In addition to lack of abortion availability in states with abortion bans, many OBGYNs in these states do not refer for abortion services either. They are more likely to say that they offer informational resources about abortion (e.g., a link to Abortion Finder or Plan C) than make referrals.

We looked at the characteristics of OBGYNs who specifically provide or refer for at least one abortion service since this offers patients a more direct connection to care. There were substantial differences between physicians who provide and refer compared to those who do not, based on the abortion policy in the state in which they practice. In states with abortion bans, 30% of OBGYNs do not even offer their patients referrals to another clinician or any information (such as online resources) about abortion, leaving those seeking abortion services without services and referrals, even if those referrals would be out of state (Figure 3).

This is not surprising in light of confusion in states like Idaho and Texas regarding the legality of abortion referrals. Texas’ SB8 prohibits aiding and abetting the provision of abortions, leaving providers afraid and reluctant to make abortion referrals. In Idaho, the Attorney General issued a letter saying Idaho law prohibits providers from referring a woman across state lines to access abortion services, but then withdrew the letter after being sued by abortion providers. Just under half (44%) of OBGYNs in states with restricted gestational limits do not provide or refer for abortion services compared to 19% in states where abortion is still available in most circumstances.

Reasons for Not Providing Abortion Services

Overall, among OBGYNs who say they do not provide any type of abortion service, the top reason (44%) is that the practice or institution where they work has a policy against performing abortions for pregnancy termination (Figure 4). This share is similar across states where abortion is banned (42%) and states with gestational restrictions (51%). Not surprisingly, an abortion ban in the state where they practice is the leading reason OBGYNs in states with abortion bans cite for not providing abortions. Roughly three in ten OBGYNs who practice in states with abortion bans or restrictions who do not provide abortions say they personally oppose the practice, and one in five say there are too many legal regulations associated with abortion. Most OBGYNs that do not provide abortion services in states with bans or restrictions cite two or more reasons for not providing abortions. In states with gestational restrictions, just over a third of OBGYNs (34%) say the reason they do not provide abortion services is because abortion is readily available in other nearby locations.

Nationally, 13% OBGYNs cite safety concerns for themselves and their staff as a reason for not providing abortion services. This is higher among OBGYNs in states with bans (16%) and gestational restrictions (18%) compared to 8% in states where abortion is available under most circumstances.

Other reasons for why OBGYNs say they do not provide abortions include lack of training or religious reasons. Others say that they specialize in infertility and abortion services are not regularly desired by their patients.

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MISCARRIAGE MANAGEMENT

Miscarriage Management among U.S. OBGYNs

Miscarriages are very common and an important aspect of many OBGYNs’ scope of practice, and sometimes involve the same procedures and medications that are used for abortions. Aspiration procedures, as well as mifepristone and misoprostol are also used to medically manage miscarriages. In early pregnancy, medical management for miscarriage with misoprostol and mifepristone allows a shorter time course than waiting for nonviable pregnancy tissue to pass on its own (expectant management) in patients without complications. Misoprostol alone can also be used for the medical management of miscarriage. Aspiration procedures are often used for individuals who are medically unstable or have an incomplete miscarriage after expectant or medical management or for patients who desire prompt resolution of their miscarriage.

Three in four OBGYNs (72%) say they provide aspiration procedures or mifepristone and misoprostol for miscarriages, far more than those who provide abortion services (Figure 5). The shares of OBGYNs providing these services was similar pre- and post-Dobbs and there is very little variation by state abortion policy or demographic characteristics. Of note, six in ten (62%) OBGYNs use mifepristone with misoprostol for miscarriage management. However, the availability of mifepristone for miscarriage management could be greatly restricted if the current litigation challenging the FDA approval of the drug results in a reversal of the approval process.

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UNDERSTANDING OF STATE ABORTION POLICIES AND CONCERNS ABOUT LEGAL RISK

Knowledge of State Abortion Laws

There are a wide variety of state laws and policies governing abortion access, availability, and provision, and since the Dobbs ruling, there have been numerous and often rapid changes in state policies. It is important for clinicians who provide sexual and reproductive health care to understand whether and when it is legal to offer abortion services. Even in states with abortion bans, there are limited exceptions, particularly for life-threatening medical emergencies, under which it should be legal to provide abortion services.

Nearly all OBGYNs (95%) say that they understand the circumstances under which abortion is legal in the state they practice—68% say they understand the circumstances very well and 27% say they understand somewhat well (Figure 6). Shares are similar across age, gender, and race/ethnicity groups. However, there is less clarity about policies among OBGYNs practicing in states with gestational restrictions where less than half say they understand the circumstances very well (45%), a lower share than those in states where abortion is banned (68%) altogether and where abortion remains available under most circumstances (79%).

Concern about Legal Risk

Abortion bans and restrictions can carry criminal penalties for clinicians that provide abortion care. Over four in ten (42%) OBGYNs report that they are very or somewhat concerned about their own legal risk when making decisions about patient care and the necessity of abortion. This is higher among OBGYNs identifying as women (47%), compared to men (34%). A higher share of OBGYNs practicing in states where abortion is banned (61%) and in states with gestational limits (59%) are concerned about their own legal risks compared to OBGYNs in states where abortion is available (27%) (Figure 7).

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CONSTRAINTS ON CARE AS A RESULT OF DOBBS

As OBGYNs worry about their legal risk, many report that Dobbs has affected their interactions with patients to the detriment of care (Figure 8). More than four in ten (44%) OBGYNs say their decision-making autonomy has become worse in the past year and over one-third (36%) say their ability to practice within the standard of care has deteriorated. Almost one in five (17%) OBGYNS say their provider-patient relationships have become worse since Dobbs. Overall, 16% of OBGYNs say the Dobbs decision has made all of these issues worse.

While many OBGYNs across the country have seen an impact of Dobbs on their practice, the effect on some of these measures varies widely between states (Figure 9). For example, 55% of OBGYNs in states with abortion bans and 47% in states with gestational limits say their ability to practice within the standard of care has worsened since Dobbs, much higher than 23% among OBGYNs in states where abortion is available under most circumstances. Similarly, three in ten OBGYNs in banned states (30%) and one in five in gestational limit states (20%) say their patient-provider relationships have worsened since Dobbs, compared to one in ten in states where abortion is available under most circumstances (11%).

A significant portion of OBGYNs say they have personally experienced limits on their professional care since the Dobbs ruling (Figure 10). Nationally, one in five say they have been constrained in providing care for miscarriages (20%) and pregnancy-related emergencies (19%) since the Dobbs ruling. About a quarter (24%) of OBGYNs say they have had a patient who tried to obtain an abortion and could not obtain one. However, all of these are more commonly reported among OBGYNs in states where abortion is banned or limited by gestational restrictions than in states where abortion is permitted under most circumstances. About four in ten OBGYNs in states where abortion is banned say they have been constrained in providing care for miscarriages (40%) and pregnancy-related medical emergencies (37%), compared to less than one in ten OBGYNs in states where abortion remains available under most circumstances. Fewer OBGYNs say a patient has asked them about how to have an abortion on their own (14%), but the share is slightly higher in states with gestational limits (18%).

Many OBGYNs also say that the Dobbs decision has had a negative impact on the broader field of maternity care. Pregnancy-related mortality (death within one year of pregnancy) has been recognized as a major public health tragedy and urgent priority for action. In particular, the share is 3-4 times higher among women who are Black, Native American, and NHOPI compared to White women. Reducing the overall rate and narrowing these disparities has been the focus of several efforts among clinicians, policymakers, and the public health community. Shortages in maternity care providers, particularly in certain regions, is one of many factors that affects pregnancy-related mortality and morbidity. These survey findings raise the alarming prospect that maternal health outcomes may worsen in the post-Roe world. Seven in ten OBGYNs say that since the Dobbs decision, racial and ethnic inequities in maternal health (70%) as well as management of pregnancy-related medical emergencies (68%) have gotten worse (Figure 11). Over half think that the ability to attract new OBGYNs to the profession has worsened (55%) and 64% think the same about pregnancy-related mortality. Interestingly, these concerns are shared by OBGYNs in states with different abortion policies. More than half of all OBGYNs across all state groupings say that these problems have become worse since Dobbs. A slightly higher share of those practicing in states where abortion is available (75%) under most circumstances say racial and ethnic inequities have worsened compared to those in states where abortion is banned (63%).

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CONTRACEPTION

Provision of Contraception

Overall, 80% of OBGYNs provide reversible contraceptive methods (other than emergency contraception) (Figure 12). Nearly all OBGYNs report that they prescribe/provide oral contraceptive pills (99%), vaginal rings (96%), the patch (95%), contraceptive injections (Depo-Provera) (93%), and intrauterine devices (IUDs) (93%). Slightly fewer provide contraceptive implants (Nexplanon) (83%). Eight in ten also provide their patients with tubal ligation procedures (81%).

When including emergency contraception (discussed below), however, about three in ten (29%) OBGYNs reported prescribing or providing all ten of the contraceptive methods asked about, including all hormonal methods (pill, patch, ring, injection, IUD and implant), tubal ligation, and all three methods of emergency contraception (copper IUD, ulipristal acetate (Ella), and Plan B).

A higher share of OBGYNs who are women compared to men, younger compared to older, work in large practices compared to medium and small, and those who provide any telehealth compared to those who do not provide telehealth report providing all methods of contraception (Figure 13). Larger shares of OBGYNs practicing in states where abortion is available under most circumstances compared to states where abortion is banned say they provide all methods of contraception (36% vs. 13%).

Provision of Emergency Contraception

Among the three commonly used methods of emergency contraception (EC), the copper IUD and ulipristal acetate/Ella must be prescribed, and levonorgestrel/Plan B can be purchased over the counter. Just over half of OBGYNs provide copper IUDs (51%) for emergency contraception and less than half provide ulipristal acetate/Ella (42%) (Figure 14). Larger shares of OBGYNs who provide copper IUDs and ulipristal acetate/Ella for emergency contraception are women, younger, work in larger practices, and provide telehealth.

There are also notable differences in the availability of EC between states with and without abortion bans and restrictions. Notably, only a quarter (25%) of OBGYNs in states with abortion bans provide ulipristal acetate/Ella and only four in ten (40%) provide copper IUDs for emergency contraception, which is lower than in states where abortion is available under most circumstances. This means that in abortion ban states, not only is abortion unavailable, but there is also limited OBGYN provision of certain emergency contraception methods. While most OBGYNs provide levonorgestrel/Plan B, this share is also lower in states where abortion is banned (73%) compared to in states where abortion is available under most circumstances (90%). There are misconceptions, even among some OBGYNs that emergency contraception and IUDs cause abortion, which could result in their unwillingness to provide or prescribe emergency contraception.

Twice as many OBGYNs provide or prescribe levonorgestrel/Plan B than ulipristal acetate/Ella, which is surprising since Plan B can be purchased over the counter, while Ella requires a prescription from a clinician. Ella is also more effective among people who are overweight or obese and has a longer window of time for use. However, in most states, Plan B must be prescribed for it to be covered by insurance. Otherwise, someone would have to pay for it out of pocket, which typically costs between $35-$49. Obtaining a prescription from a clinician can also help alleviate some other barriers to obtaining Plan B pills, such as when stores do not stock it or lock it in a case.

Only a third of OBGYNs (34%) prescribe or provide all three methods of emergency contraception and one in seven (15%) do not provide any methods of emergency contraception. A quarter of OBGYNS (25%) only prescribe or provide Plan B (Figure 15).

Many OBGYNs report that they have seen a rise in the share of their patients seeking contraception since the Dobbs ruling. Overall, more than half (55%) of OBGYNs say they have seen an increase in the share of patients seeking at least one form of contraception since the Dobbs ruling. In particular, a substantial share of OBGYNs report more patients are interested in sterilization and LARCs over the past year. One in five OBGYNs (21%) say that they have seen a lot of increase in the share of patients seeking sterilization and another one in five (22%) have seen some increase (Figure 16). More than one in ten (15%) say the share of patients seeking LARCs has increased a lot and another 32% say there has been some increase. Just over half (52%) though say there has been no change. OBGYNs report more modest rises in patients seeking EC pills (21% a lot or somewhat) and other hormonal methods, which include oral contraceptives, Depo injections, patch, and ring (25% a lot or somewhat). About three-quarters of OBGYNs say that there has been no change in the share of patients seeking EC (78%) or other hormonal methods (73%) since the Dobbs ruling.

The increased interest in contraception is more pronounced in states where abortion is banned or greatly limited by gestational limits (Figure 17). For example, about half of OBGYNs in these states say the share of patients seeking sterilization has increased since Dobbs, higher than in states where abortion remains available under most circumstances. This pattern is similar for other hormonal methods too. About one-third of OBGYNs in states where abortion is banned or with gestational restrictions say they have seen an increase in patients seeking other hormonal methods, compared to 18% of OBGYNs in states where abortion is available under most circumstances.

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ADDITIONAL AVENUES OF CARE

Telehealth

While the Dobbs decision has significantly changed the provision of health care, the COVID-19 pandemic also significantly expanded provider use of telehealth services. In 2020, the KFF National Physician Survey found that prior to March 1, 2020, just 12% of OBGYNs were using telehealth, which dramatically increased to 84% using telehealth by June 2020. In the 2023 survey we found 69% of OBGYNs were providing some services through telehealth, with about a third saying they did not (31%) provide any care via telehealth (Figure 18). Larger shares of OBGYNs who are women, younger, and provide or refer for abortion services, as well as practice in a state where abortion is available under most circumstances say they currently provide telehealth. Some patients that relied on telehealth services during the height of the pandemic may find that their provider is no longer providing telehealth services.

Pharmacy Dispensing of Medication Abortion

For many years, FDA policy required that mifepristone pills could only be dispensed by a clinician who was certified to prescribe the drug at an in-person medical appointment. However, in December 2021, the FDA adopted expanded the distribution to include certified pharmacies in addition to certified clinicians. This change removed the previous requirement to dispense the medication in person and expanded the opportunity for telehealth in states that have not banned abortion. Subsequently, on January 3, 2023, the FDA approved a protocol for pharmacies, allowing those that have been certified by the manufacturers to dispense mifepristone directly to patients. However, the FDA’s initial approval of mifepristone in 2000 is currently being challenged in federal courts.

This survey asked OBGYNs if they had heard about the most recent FDA policy change allowing pharmacies to dispense medication abortion pills to patients. Two-thirds of OBGYNs (67%) report that they have heard a lot or some about the FDA’s policy change, and 33% have heard very little or nothing at all (Figure 19). Fewer OBGYNs practicing in states where abortion is banned (56%) report having heard of the policy change compared to OBGYNs practicing in states where abortion is restricted by gestational limits (67%) or is available (71%).

There is broad support among OBGYNs (80%) for the FDA change that allows certified pharmacies to dispense medication abortion pills to patients while 20% are opposed (Figure 20). Notably, support is consistently high across OBGYNs in states with differing abortion policies. Eight in ten OBGYNs practicing in states where abortion is available (82%) and in states where abortion is restricted (82%) support allowing pharmacies to dispense medication abortion as do 73% of those practicing in states where abortion is banned. Larger shares of OBGYNs under the age of 55 (89%), who are women (85%), or who work in midsize (84%) support this policy compared to OBGYNs who are over the age of 55 (69%), who are men (71%) or work in smaller practices (73%).

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Looking Forward

The Supreme Court’s Dobbs decision not only affected abortion access, but it substantially changed many aspects of the provision of reproductive health care across the country. While the majority of OBGYNs do not provide abortion services, most OBGYNs do provide miscarriage management using the same procedures and medications that are used for abortions. Four in ten OBGYNs in states where abortion is illegal report constraints on their ability to manage miscarriages and pregnancy-related medical emergencies. Many also say their decision-making autonomy, the ability to practice within the standard of care, and their provider-patient relationships have been worsened by the Dobbs decision. Most are also concerned that pregnancy-related mortality and maternal health disparities have gotten worse as a result of the ruling. Some of the states with abortion bans and restrictions already had some of the poorest maternal and infant health outcomes.

The effects of the Dobbs decision on patient care are only beginning to be seen. In some states where abortion was not immediately banned, policymakers continue to pass laws to ban or seek to limit abortion services, leaving more patients without access and requiring longer travel distances for those that are not able to get abortion care where they live. These policies place additional demand on clinicians providing abortions in states where abortion is still available under most circumstances, but the share of OBGYNs that offer abortion services has not increased. Additionally, there has already been a decline in medical students applying to residencies in states where abortion is banned because they cannot receive the full spectrum of training. Over time, this could leave large parts of the country with shortages of trained OBGYNs that will affect not only abortion services but also other pregnancy-related services.

Methods Summary

The KFF 2023 National OBGYN Survey obtained responses from a nationally representative sample of OBGYNs practicing in the United States who provide sexual and reproductive health care to patients in office-based settings. The survey was designed and analyzed by researchers at KFF, and an independent research company, SSRS, carried out the fieldwork and collaborated on questionnaire design, pretesting, sample design, and weighting. Survey responses were collected via paper and online questionnaires from March 17 to May 18, 2023 from 569 OBGYNs.

Providers were sent an up-front cash $20 incentive in the first mailing to encourage respondents to complete the survey.

The response rate for eligible OBGYNs was 29.9% and was calculated using AAPOR’s RR3. Overall, 39% of qualified OBGYNs completed the survey by web and 61% completed by mail.

The samples were weighted to match known demographics. Taking into account the design effect, the margin of sampling error for results based on total OBGYNs is +/- 5 percentage points at the 95% confidence level. Margins of sampling error for the state groupings are +/- 7% in states where abortion is available under most circumstances, +/- 7% in states with gestational limits, and +/- 7% in states where abortion is banned. Please see the attached topline for the full methodology report.

Sample Overview

We surveyed a nationally representative sample of 569 U.S. OBGYNs currently in clinical practice. Eligible physicians were board-certified OBGYNs who spend at least 60% of their time providing direct patient care and provide sexual and reproductive health care to at least 10% of their patients in an office-based setting. We compared survey responses by key physician and practice characteristics. Gender, age and race were determined by physician self-report. Practice size was determined by the number of full-time equivalent (FTE) physicians or advance practice clinicians (small <4, medium 4-10, large > 10). Sampling was conducted to ensure an adequate sample of OBGYNs in states where abortion was available under most circumstances, meaning that it is legal without pre-viability gestational limits, during the survey field period: AK, CA, CO, CT, DC, DE, HI, IL, MA, MD, ME, MI, MN, MT, NH, NJ, NM, NV, NY, OR, PA, RI, VA, VT, WA, WY; states with pre-viability gestational restrictions during the survey field period: AZ, FL, GA, IA, IN, KS, NC, ND, NE, OH, SC, UT; and states where abortion was banned during the survey field period: AL, AR, ID, KY, LA, MO, MS, OK, SD, TN, TX, WI, WV. During the field period, there was a change in policy in ND and abortion is now banned. ND remains in the gestational limits category for this analysis, as that was the status of the state’s policy for most of the field period.

Characteristics of Survey Respondents

Table 2 shows the demographics of the survey respondents. More than six in ten are women (64%), most were under the age of 55 (57%), 68% are White, 14% Asian, 6% Black, and 7% Hispanic. The majority of OBGYNs surveyed work in private office-based practices (83% in solo, group or hospital owned private practice or HMOs and  other private practices). A minority practiced in what was defined as a health center/clinic (14%). Just over four in ten (46%) OBGYNs work in medium size practices with 4-10 clinicians, and the majority practice in urban/suburban locations (90%). Half (54%) practice in states where abortion is available under most circumstances, 25% in states with pre-viability gestational restrictions, and 21% in states where abortion is banned.