Alabama Gov. Kay Ivey on May 15 signed into law the strictest abortion ban in the country, sparking fears not only about abortion access, but also about how the policy could worsen disparities that already endanger the health of women living in the south.
The law, set to become enforceable in six months, bans nearly all abortions at all stages of pregnancy, with exceptions only for serious threats to the mother’s health. It also makes performing abortions a crime for doctors, who could be convicted of a felony and face up to 99 years in prison. Until the law is enforced, abortion is still legally available in Alabama.
Abortion advocates and the American Civil Liberties Union have both vowed to bring legal action against the ban, which is intended to challenge the landmark Supreme Court ruling Roe v. Wade, and say they are confident it will be found unconstitutional before it ever affects abortion access. But even if it is never enforced, opponents say the policy, and others like it introduced recently in nearby states including Georgia, Kentucky and Mississippi, could dissuade doctors from practicing in the Southeast, an area already grappling with physician shortages and health inequities.
“This law is putting doctors in an impossible position. Alabama is already facing a critical shortage of OB/GYNs, and this is going to further reduce health care access in a state that certainly needs it,” says Planned Parenthood President Dr. Leana Wen. And without exceptions in the law for rape and incest, “the doctor who provides abortion care could go to jail for longer than the rapist. What kind of dystopian world do we live in?”
Already in Alabama, which has one of the country’s highest cervical cancer mortality rates and a rising maternal mortality rate, women in many counties lack convenient access to obstetric and gynecological care. Only eight more OB/GYNs moved into the state than left it from 2006 to 2015, according to a report from the American Congress of Obstetricians and Gynecologists (ACOG), and during the same time period, the number of adult Alabama women per OB/GYN grew from almost 3,700 to more than 4,200.
“Criminalizing OB/GYNs and their medical practice isn’t going to help Alabama attract and retain talent,” says Staci Fox, president and CEO of Planned Parenthood Southeast. “I’m afraid they’ll leave—not just doctors who are coming in to provide abortions at our health centers, but also OB/GYNs.”
When asked about potential doctor attrition, a press representative for Gov. Ivey directed TIME to the governor’s original statement on the abortion ban.
The problem isn’t unique to Alabama. The U.S. as a whole faces a serious physician shortage, in areas including obstetrics and gynecology. The Association of American Medical Colleges (AAMC) estimates that by 2032, the country will be short between 46,900 and 121,900 doctors as demand outpaces supply, aging doctors retire faster than they can be replaced and trainees disproportionately choose to practice in urban areas and certain high-paying medical specialties. As soon as next year, the AAMC says, the U.S. may be short up to 8,000 OB/GYNs alone.
The problem is especially severe in the South, where the gap between supply and demand for doctors is wider than in other regions, according to AAMC data. Rates of chronic health conditions like obesity, diabetes and heart disease are highest in the region, and rates of infant mortality, congenital syphilis and ovarian cancer mortality are also high there. Those in rural and lower-socioeconomic areas, who tend to need medical attention at higher-than-average rates, may find it especially difficult to get the care they need.
Though the ACOG report does not track why doctors leave or move into certain states, it did find that 61 more doctors moved out of Louisiana than moved into it between 2005 and 2016, and five more left Mississippi. Abortion-restricting policies were enacted in both Louisiana and Mississippi in 2014.
“I do worry about the pipeline of providers that will choose to work in such hostile states, where not only are the laws challenging to overcome,” but also the safety of providers may be at risk due to anti-abortion sentiment, says Kwajelyn Jackson, executive director of Atlanta abortion provider Feminist Women’s Health Center. “Those things I consider the likely outcomes, even if we are able to continue to hold the laws at bay.”
Research has also shown that restrictive abortion access is associated with delays in care, poorer mental health and a higher risk of self-induced or unsafe abortions.
Dr. Tiffany Hailstorks, an abortion provider and an assistant professor of gynecology and obstetrics at Emory University in Atlanta says these issues were an important consideration when she moved from Washington, D.C. to Georgia about four years ago.
“I wanted to be able to practice comprehensive women’s health care, including abortion care,” Hailstorks says. “Even in those four years, it has changed drastically.”
Hailstorks says she’s not going anywhere—”The women in Georgia need providers. I’m invested in providing healthcare to them, and to help fight this battle along with them,” she says—but she’s not sure that will always be the case for her colleagues, or for new doctors deciding where to practice.
“It’s just a tough spot for physicians. Do we honor the oath that we took to take care of patients and practice evidence-based medicine, or do we practice in fear because of the potential criminalization of doctors?” she says. “I think the law will deter even more doctors from practicing in certain states with restrictions, out of this fear.”