On June 24, 2022, the U.S. Supreme Court released its decision on Dobbs v Jackson Women's Health Organization. The Supreme Court ruled that there is no constitutional protection for abortion, overturning the precedents established in Roe v Wade and Planned Parenthood v Casey and enabling states to restrict or ban abortion with preexisting laws or new legislation.

In response, 75 health care organizations, including the American Academy of Family Physicians, released a statement emphasizing that the Dobbs ruling criminalizes evidence-based medicine, threatens the patient-clinician relationship, and exacerbates stark health disparities in maternal morbidity and mortality.^1,2

The Dobbs ruling has created a public health crisis. The decision has led to confusion for patients and clinicians about legal rights to abortion care that now differ substantially from state to state. There is also confusion about the legal risks for providing other reproductive health care (e.g., management of ectopic pregnancy and miscarriage, pregnancy termination for medical reasons), seeking or disseminating information, and providing funding and practical support.

Health policy analysts predict that 26 states are certain or likely to ban abortion.³ Many states had laws banning abortion that were unenforceable after the Supreme Court's Roe v Wade decision in 1973, but those laws are now active. Other states enacted trigger bans, designed to outlaw abortion following any Supreme Court decision limiting or overturning Roe v Wade. As of January 2023, a total ban or a ban past six weeks' gestational age was in effect in 14 states.^4–6 Some state laws have no exemptions for rape or incest, and a number of laws have been challenged in state courts.

In the years leading up to the Dobbs decision, abortion restrictions accelerated on the state level. State legislatures passed 108 abortion restrictions in 19 states in 2021, the highest number in any year since 1973.⁷ Texas' Senate Bill 8 took effect in September 2021, and similar laws emerged in Oklahoma and Idaho. These laws ban abortion at an early gestational age and are enforced by private citizens who stand to receive financial compensation for suing abortion providers and anyone who “aids or abets” abortion care.⁸

In states with abortion bans, physicians have had to reconcile the law with their clinical recommendations for ectopic pregnancy, molar pregnancy, miscarriage, previable rupture of membranes, comorbid conditions not compatible with pregnancy, and pregnancy following rape. The laws are broad without clear guidelines. For example, consider a patient experiencing previable rupture of membranes at 17 weeks' gestation in a state with an abortion ban. Although an exemption for the patient's life exists in her state, the law does not define when her situation becomes life-threatening. It is not clear if this determination is at the discretion of the physician or if certain parameters such as sepsis or severe anemia would be required.

There is tremendous confusion about how to reconcile new, untested laws with evidence-based guidelines from medical organizations. Between 2000 and 2020, there have been 61 cases identified where people were criminally investigated or arrested for allegedly ending their pregnancies or assisting another person to end a pregnancy.^9,10 Self-managed abortion refers to actions that take place outside of the health care setting, such as self-sourcing mifepristone and misoprostol, consuming herbs or toxic substances, and using physical methods. Medical organizations oppose criminalization of self-managed abortion, and the safety and effectiveness of self-managed medication abortion have been established.^11–14 However, legal and policy experts in reproductive rights anticipate a nationwide surge in criminal action against pregnant people as individuals lose access to clinical abortion care and states further restrict access.^9–11

On June 28, 2022, the U.S. Department of Health and Human Services released additional guidance about the Health Insurance Portability and Accountability Act (HIPAA), which protects against disclosures of protected health information. HIPAA prohibits disclosure of personal health information to law enforcement unless a court-ordered warrant or subpoena is provided or the disclosure is expressly required by law. Reporting personal health information to law enforcement regarding abortion or other pregnancy outcomes may violate HIPAA.¹⁵ An attorney with the National Advocates for Pregnant Women warns that the most common way pregnancy criminalization begins is by a health care worker reporting a patient.¹⁶

The Centers for Medicare and Medicaid Services (CMS) released updated guidance in July 2022 regarding the Emergency Medical Treatment and Labor Act, which requires any Medicare-participating hospital that offers emergency services to provide an examination and stabilizing treatment for emergency medical conditions. According to CMS, if a pregnant patient has an emergency medical condition and abortion is stabilizing treatment, the Emergency Medical Treatment and Labor Act supersedes state law. However, in August 2022, a Texas court filed a temporary injunction against enforcement, and litigation is ongoing.^17,18

Experts from the medical, legal, and policy fields are working together to understand the post–Roe v Wade medicolegal landscape and to convey best practices to clinicians. As laws evolve, family physicians across the country should be aware of resources for evidence-based medical care and current health policy, and legal information for themselves and patients. Resources are summarized in Table 1.